Healthcare Provider Details

I. General information

NPI: 1316181597
Provider Name (Legal Business Name): AUNT MARTHA'S YOUTH SERVICE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WOLPERS RD
PARK FOREST IL
60466
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 Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

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