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General NPI Number Information
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NPI Number | 1386906139
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Entity Type | Organization
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Legal Business Name | OPEN WINGS LEARNING COMMUNITY
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Dates
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Enumeration Date | 06/07/2012
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Last Update Date | 06/07/2012
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Provider Practice Location Address
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Address Line | 778 W FRONTAGE RD STE. 123
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City | NORTHFIELD
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State | IL
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Zip | 60093-1209
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Country | US
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Telephone | 312-587-1742
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Fax | 312-376-1047
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Provider Business Mailing Address
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Address Line | 778 W FRONTAGE RD STE. 123
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City | NORTHFIELD
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State | IL
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Zip | 60093-1209
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Country | US
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Telephone | 312-587-1742
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Fax | 312-376-1047
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. ROBERT E DANIELS
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Credential | PH.D.
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Telephone | 312-587-1742
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 071-006306
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License Number State | IL
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