Provider Demographics
NPI:1093060741
Name:WAY BACK INN
Entity Type:Organization
Organization Name:WAY BACK INN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:PINDIUR
Authorized Official - Suffix:
Authorized Official - Credentials:MS LCPC
Authorized Official - Phone:708-344-3301
Mailing Address - Street 1:104 OAK ST.
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-344-3301
Mailing Address - Fax:708-344-2944
Practice Address - Street 1:104 OAK ST.
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-344-3301
Practice Address - Fax:708-344-2944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAY BACK INN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-18
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007242101YA0400X, 101YP2500X
IL180.007316101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty