MEDICARE: AUNT MARTHA'S YOUTH SERVICE CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295835023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUNT MARTHA'S YOUTH SERVICE CENTER

Provider Business Mailing Address
First Line	:	19990 GOVERNORS HWY
Second Line	:
City	:	OLYMPIA FIELDS
State	:	IL
Zip	:	60461-1021
Country	:	US
Telephone Number	:	708-747-7100
Fax Number	:	708-747-0710

Provider Business Practice Location Address
First Line	:	8640 S SOUTH CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-2314
Country	:	US
Telephone Number	:	773-731-9100
Fax Number	:	708-747-7907

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MARY MARTIN
Credential	:
Telephone Number	:	708-825-5976

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	03/08/2017

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