Provider Demographics
NPI:1528319969
Name:ARDEN SHORE CHILD AND FAMILY SERVICES
Entity type:Organization
Organization Name:ARDEN SHORE CHILD AND FAMILY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-623-1730
Mailing Address - Street 1:3100 CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60087-2247
Mailing Address - Country:US
Mailing Address - Phone:847-263-1858
Mailing Address - Fax:847-263-4190
Practice Address - Street 1:3100 CORNELL RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087-2247
Practice Address - Country:US
Practice Address - Phone:847-263-1858
Practice Address - Fax:847-263-4190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL31414206322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children