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General NPI Number Information
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NPI Number | 1114861259
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Entity Type | Organization
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Legal Business Name | MARYVILLE ACADEMY
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Dates
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Enumeration Date | 04/17/2026
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Last Update Date | 04/17/2026
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Provider Practice Location Address
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Address Line | 4909 W DIVISION ST STE 407
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City | CHICAGO
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State | IL
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Zip | 60651-3161
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Country | US
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Telephone | 847-390-3004
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Fax |
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Provider Business Mailing Address
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Address Line | 4909 W DIVISION ST STE 407
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City | CHICAGO
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State | IL
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Zip | 60651-3161
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Country | US
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Telephone | 847-390-3004
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR OF COMMUNITY SERVICES
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Name | FREDERICK SMITH
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Credential |
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Telephone | 847-390-3004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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