Provider Demographics
NPI:1073685715
Name:LDS FAMILY SERVICES
Entity Type:Organization
Organization Name:LDS FAMILY SERVICES
Other - Org Name:LDS FAMILY SERVICES IL CHICAGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:630-942-8803
Mailing Address - Street 1:1320 RIDGELAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1546
Mailing Address - Country:US
Mailing Address - Phone:630-942-8803
Mailing Address - Fax:630-942-8845
Practice Address - Street 1:1320 RIDGELAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1546
Practice Address - Country:US
Practice Address - Phone:630-942-8803
Practice Address - Fax:630-942-8845
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LDS FAMILY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-15
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL37747403261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
2232813OtherBCBS
870489316OtherFEDERAL TAX ID NUMBER