Healthcare Provider Details

I. General information

NPI: 1356860571
Provider Name (Legal Business Name): JUDSON UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N STATE ST
ELGIN IL
60123-1404
US

IV. Provider business mailing address

1151 N STATE ST
ELGIN IL
60123-1404
US

V. Phone/Fax

Practice location:
  • Phone: 847-628-2464
  • Fax: 847-628-2044
Mailing address:
  • Phone: 847-628-2464
  • Fax: 847-628-2044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAROL DIDOMINICIS
Title or Position: CLINICAL SUPERVISOR
Credential: LCSW
Phone: 847-628-2464