Provider Demographics
NPI:1043271190
Name:NORMAN C SLEEZER YOUTH HOME
Entity Type:Organization
Organization Name:NORMAN C SLEEZER YOUTH HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:STATZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:815-232-8336
Mailing Address - Street 1:PO BOX 895
Mailing Address - Street 2:1401 S SLEEZER HOME ROAD
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032
Mailing Address - Country:US
Mailing Address - Phone:815-232-8336
Mailing Address - Fax:815-232-8842
Practice Address - Street 1:1401 S SLEEZER HOME ROAD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032
Practice Address - Country:US
Practice Address - Phone:815-232-8336
Practice Address - Fax:815-232-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05CHR046Medicaid