Healthcare Provider Details

I. General information

NPI: 1205006681
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5825 W BELMONT AVE
CHICAGO IL
60634-5203
US

IV. Provider business mailing address

1001 E TOUHY AVE SUITE 170
DES PLAINES IL
60018-5801
US

V. Phone/Fax

Practice location:
  • Phone: 773-745-9870
  • Fax: 773-745-9892
Mailing address:
  • Phone: 847-635-4600
  • Fax: 847-297-3407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. TIMOTHY J. SHEEHAN
Title or Position: VICE PRESIDENT
Credential:
Phone: 847-635-4600