Healthcare Provider Details

I. General information

NPI: 1578942108
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1798 SUMMIT AVE STE 104
EAST SAINT LOUIS IL
62205-2800
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 618-604-3459
  • Fax: 618-875-9695
Mailing address:
  • Phone: 847-635-4600
  • Fax: 847-297-3314

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 Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: GREERANN HAMBLET
Title or Position: BUSINESS MANAGER
Credential:
Phone: 847-390-1422