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General NPI Number Information
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NPI Number | 1184826422
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Entity Type | Organization
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Legal Business Name | AUNT MARTHAS YOUTH SERVICE CTR
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 233 W JOE ORR RD
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411-1744
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Country | US
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Telephone | 708-754-1044
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Fax |
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Provider Business Mailing Address
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Address Line | 440 FOREST BLVD
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City | PARK FOREST
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State | IL
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Zip | 60466-2002
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Country | US
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Telephone | 708-679-8000
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Fax |
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. GERALD GARVEY
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Credential |
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Telephone | 708-754-1044
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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 | 002
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License Number State | IL
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