Provider Demographics
NPI:1164757266
Name:YOUTH SERVICE BUREAU OF ILLINOIS VALLEY
Entity Type:Organization
Organization Name:YOUTH SERVICE BUREAU OF ILLINOIS VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:815-431-3022
Mailing Address - Street 1:424 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-2833
Mailing Address - Country:US
Mailing Address - Phone:815-433-3953
Mailing Address - Fax:815-433-3980
Practice Address - Street 1:424 W MADISON ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-2833
Practice Address - Country:US
Practice Address - Phone:815-433-3953
Practice Address - Fax:815-433-3980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.013808251S00000X
IL1041C0700X251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.013808OtherLICENSED CLINICAL SOCIAL WORKER