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General NPI Number Information
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NPI Number | 1558690628
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Entity Type | Organization
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Legal Business Name | LOYOLA UNIVERSITY SCHOOL OF NURSING - SCHOOL-BASED HEALTH CENTER
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Dates
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Enumeration Date | 12/18/2009
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Last Update Date | 12/18/2009
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Provider Practice Location Address
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Address Line | 807 SOUTH FIRST AVENUE SCHOOL-BASED HEALTH CENTER AT PROVISO EAST HIGH SCHOOL
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City | MAYWOOD
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State | IL
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Zip | 60153
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Country | US
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Telephone | 708-449-9522
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Fax | 708-449-9525
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Provider Business Mailing Address
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Address Line | 2160 SOUTH FIRST AVENUE MAGUIRE - 105-2840
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City | MAYWOOD
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State | IL
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Zip | 60153
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Country | US
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Telephone | 708-449-9522
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Fax | 708-449-9525
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Authorized Official
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Title or Position | PROJECT DIRECTOR: LOYOLA UNIVERSITY
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Name | DR. DIANA P. HACKBARTH
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Credential | PHD, RN, FAAN
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Telephone | 708-216-3670
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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