=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689907818
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHBROOK ELE SCH DIS 28
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2009
-----------------------------------------------------
Last Update Date | 03/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1475 MAPLE AVE
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-5418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-504-3409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1475 MAPLE AVE
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-5418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-504-3406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSISTANT
-----------------------------------------------------
Name | KAREN HANUSIAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-504-3409
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------