Healthcare Provider Details

I. General information

NPI: 1518790559
Provider Name (Legal Business Name): PROVIDENCE FARM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CENTRAL AVE STE 340
NORTHFIELD IL
60093-3039
US

IV. Provider business mailing address

400 CENTRAL AVE STE 340
NORTHFIELD IL
60093-3039
US

V. Phone/Fax

Practice location:
  • Phone: 847-409-6230
  • Fax:
Mailing address:
  • Phone: 847-409-6230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: STEPHANIE ZWILLING
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 847-409-6230