=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396009445
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAWRENCE HALL YOUTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2012
-----------------------------------------------------
Last Update Date | 07/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8117 S ESSEX AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-1225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-728-2807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2737 W PETERSON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60659-3927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-728-2807
-----------------------------------------------------
Fax | 773-728-0751
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MARK NUFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-728-2807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number | 12057809
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------