Healthcare Provider Details

I. General information

NPI: 1467909275
Provider Name (Legal Business Name): MARYVILLE ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 LEE ST STE 100
DES PLAINES IL
60016-4543
US

IV. Provider business mailing address

701 LEE ST STE 100
DES PLAINES IL
60016-4543
US

V. Phone/Fax

Practice location:
  • Phone: 847-390-3004
  • Fax: 847-390-3016
Mailing address:
  • Phone: 847-390-3004
  • Fax: 847-390-3016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberIL
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SR. CATHERINE M RYAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 847-294-1893