Healthcare Provider Details

I. General information

NPI: 1558391656
Provider Name (Legal Business Name): MARYVILLE ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WILSON LN
DES PLAINES IL
60016-4729
US

IV. Provider business mailing address

1150 N RIVER RD
DES PLAINES IL
60016-1214
US

V. Phone/Fax

Practice location:
  • Phone: 847-768-5461
  • Fax: 847-768-5478
Mailing address:
  • Phone: 847-294-1899
  • Fax: 847-294-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number240521-04
License Number StateIL

VIII. Authorized Official

Name: NANCY Z WOULFE
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential:
Phone: 847-294-1910