Provider Demographics
NPI:1760283451
Name:MARYVILLE ACADEMY
Entity type:Organization
Organization Name:MARYVILLE ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR OF COMMUNITY SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-390-3004
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:847-294-1910
Mailing Address - Fax:
Practice Address - Street 1:951 W BARTLETT RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4479
Practice Address - Country:US
Practice Address - Phone:630-736-7450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYVILLE ACADEMY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility