Provider Demographics
NPI:1093265126
Name:ASSOCIATION FOR INDIVIDUAL DEVELOPMENT
Entity Type:Organization
Organization Name:ASSOCIATION FOR INDIVIDUAL DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PROFESSIONAL
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:OLDMEN
Authorized Official - Last Name:JALLOH
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:331-425-5280
Mailing Address - Street 1:1230 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1401
Mailing Address - Country:US
Mailing Address - Phone:630-966-4000
Mailing Address - Fax:
Practice Address - Street 1:1230 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1401
Practice Address - Country:US
Practice Address - Phone:630-966-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities