MEDICARE: MARYVILLE ACADEMY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1902353782
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	:

Provider Business Practice Location Address
First Line	:	1658 W GRAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-6309
Country	:	US
Telephone Number	:	312-491-3530
Fax Number	:

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

Provider Enumeration Date	:	09/08/2016
Last Update Date	:	07/11/2022

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Directions to “MARYVILLE ACADEMY ” Practice Location

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