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General NPI Number Information
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NPI Number | 1477700474
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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 | 08/20/2008
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Last Update Date | 08/20/2008
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Provider Practice Location Address
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Address Line | 10102 FARM SCHOOL RD
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City | DURAND
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State | IL
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Zip | 61024-9725
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Country | US
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Telephone | 815-599-3801
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Fax |
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Provider Business Mailing Address
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Address Line | 1150 N RIVER RD
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City | DES PLAINES
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State | IL
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Zip | 60016-1214
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CONTROLLER
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Name | MISS MAURA HARRINGTON
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Credential |
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Telephone | 847-294-1826
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 106103
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License Number State | IL
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