Provider Demographics
NPI:1114049483
Name:INDIVIDUALIZED AGING SERVICES
Entity Type:Organization
Organization Name:INDIVIDUALIZED AGING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ASENATH
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:312-842-4858
Mailing Address - Street 1:533 E 33RD PL
Mailing Address - Street 2:303
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4112
Mailing Address - Country:US
Mailing Address - Phone:312-842-4858
Mailing Address - Fax:312-225-5076
Practice Address - Street 1:533 E 33RD PL
Practice Address - Street 2:303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4112
Practice Address - Country:US
Practice Address - Phone:312-842-4858
Practice Address - Fax:312-225-5076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health