Healthcare Provider Details

I. General information

NPI: 1801248414
Provider Name (Legal Business Name): ASSOCIATION FOR INDIVIDUAL DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5342 W ELM ST
MCHENRY IL
60050-4029
US

IV. Provider business mailing address

5342 W ELM ST
MCHENRY IL
60050-4029
US

V. Phone/Fax

Practice location:
  • Phone: 630-859-1291
  • Fax: 815-344-2497
Mailing address:
  • Phone: 630-859-1291
  • Fax: 815-344-2497

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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: FRANCES L. BAKER
Title or Position: PRESIDENT
Credential:
Phone: 630-966-4001