Healthcare Provider Details

I. General information

NPI: 1548594088
Provider Name (Legal Business Name): AUNT MARTHA'S YOUTH SERVICE CENTER IN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W JEFFERSON ST
JOLIET IL
60435-7415
US

IV. Provider business mailing address

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461-1021
US

V. Phone/Fax

Practice location:
  • Phone: 815-768-8750
  • Fax: 815-722-1917
Mailing address:
  • Phone: 708-747-7100
  • Fax: 708-747-0710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER J NORDLOH
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 708-747-7100