=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821386236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVENTURE WORKS OF DEKALB COUNTY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2011
-----------------------------------------------------
Last Update Date | 06/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1211 SYCAMORE RD
-----------------------------------------------------
City | DEKALB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60115-2484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-517-0825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1211 SYCAMORE RD
-----------------------------------------------------
City | DEKALB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60115-2484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-517-0825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | LYNETTE SPENCER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 847-867-8936
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149007034
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------