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General NPI Number Information
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NPI Number | 1093060741
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Entity Type | Organization
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Legal Business Name | WAY BACK INN
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Dates
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Enumeration Date | 07/18/2012
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Last Update Date | 08/23/2022
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Provider Practice Location Address
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Address Line | 104 OAK ST.
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City | MAYWOOD
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State | IL
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Zip | 60153
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Country | US
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Telephone | 708-344-3301
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Fax | 708-344-2944
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Provider Business Mailing Address
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Address Line | 104 OAK ST.
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City | MAYWOOD
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State | IL
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Zip | 60153
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Country | US
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Telephone | 708-344-3301
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Fax | 708-344-2944
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Authorized Official
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Title or Position | INTERIM EXECUTIVE DIRECTOR
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Name | MS. ANITA MARIA PINDIUR
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Credential | M.S. L.C.P.C
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Telephone | 708-344-3301
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 180.007316
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.007242
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.007316
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 180.007242
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License Number State | IL
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