Healthcare Provider Details

I. General information

NPI: 1013045707
Provider Name (Legal Business Name): AUNT MARTHAS YOUTH SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461-1021
US

IV. Provider business mailing address

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461-1021
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-7100
  • Fax:
Mailing address:
  • Phone: 708-747-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number041
License Number StateIL

VIII. Authorized Official

Name: MRS. MARY M MARTIN
Title or Position: CONTROLLER
Credential:
Phone: 708-747-7100