Provider Demographics
NPI:1518790559
Name:PROVIDENCE FARM
Entity type:Organization
Organization Name:PROVIDENCE FARM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZWILLING
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-409-6230
Mailing Address - Street 1:400 CENTRAL AVE STE 340
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3039
Mailing Address - Country:US
Mailing Address - Phone:847-409-6230
Mailing Address - Fax:
Practice Address - Street 1:400 CENTRAL AVE STE 340
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3039
Practice Address - Country:US
Practice Address - Phone:847-409-6230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE FARM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health