Provider Demographics
NPI:1902353782
Name:MARYVILLE ACADEMY
Entity Type:Organization
Organization Name:MARYVILLE ACADEMY
Other - Org Name:FAMILY BEHAVIORAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:Z
Authorized Official - Last Name:WOULFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-294-1910
Mailing Address - Street 1:1150 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1214
Mailing Address - Country:US
Mailing Address - Phone:847-294-1999
Mailing Address - Fax:
Practice Address - Street 1:1658 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-6309
Practice Address - Country:US
Practice Address - Phone:312-491-3530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health