MEDICARE: MARYVILLE ACADEMY

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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1508174749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARYVILLE ACADEMY

Provider Business Mailing Address
First Line	:	1150 N RIVER RD
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60016-1214
Country	:	US
Telephone Number	:	847-294-1999
Fax Number	:	847-294-2892

Provider Business Practice Location Address
First Line	:	1658 W GRAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-6309
Country	:	US
Telephone Number	:	312-491-3500
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF BUSINESS DEVELOPMENT
Name	:	NANCY Z WOULFE
Credential	:
Telephone Number	:	847-294-1910

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	07/08/2022

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Directions to “MARYVILLE ACADEMY ” Practice Location

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