Provider Demographics
NPI:1043304546
Name:LEYDEN FAMILY SERVICE & MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:LEYDEN FAMILY SERVICE & MENTAL HEALTH CENTER
Other - Org Name:THE SHARE PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-451-0330
Mailing Address - Street 1:1776 MOON LAKE BLVD.
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169
Mailing Address - Country:US
Mailing Address - Phone:847-882-4181
Mailing Address - Fax:847-882-4299
Practice Address - Street 1:1776 MOON LAKE BLVD.
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169
Practice Address - Country:US
Practice Address - Phone:847-882-4181
Practice Address - Fax:847-882-4299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0352-0003-A261QR0405X
ILA0352-0003-A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL293079OtherVALUE OPTION ID
IL7942353OtherAETNA ID
IL50069OtherBLUE CROSS/BLUE SHIELD ID
IL7942353OtherAETNA ID