Healthcare Provider Details

I. General information

NPI: 1205209715
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICES OF IL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E DEYOUNG ST STE B
MARION IL
62959-2724
US

IV. Provider business mailing address

1001 E TOUHY AVE STE 170
DES PLAINES IL
60018-5800
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-9076
  • Fax:
Mailing address:
  • Phone: 847-635-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TIM SHEEHAN
Title or Position: VP OF HOME AND COMMUNITY SVCS
Credential:
Phone: 773-443-3562