Provider Demographics
NPI:1124401179
Name:OMNI YOUTH SERVICES, INC.
Entity Type:Organization
Organization Name:OMNI YOUTH SERVICES, INC.
Other - Org Name:EDGE COUNSELING SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:EGGER
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:847-353-1762
Mailing Address - Street 1:1111 W LAKE COOK RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60689
Mailing Address - Country:US
Mailing Address - Phone:847-353-1500
Mailing Address - Fax:847-465-1964
Practice Address - Street 1:1111 W LAKE COOK RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60689
Practice Address - Country:US
Practice Address - Phone:847-353-1500
Practice Address - Fax:847-465-1964
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OMNI YOUTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-08
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health