Provider Demographics
NPI:1164886297
Name:FORTYTHIRTYONE, INC
Entity Type:Organization
Organization Name:FORTYTHIRTYONE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NADA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRZOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-827-0600
Mailing Address - Street 1:1580 N NORTHWEST HWY
Mailing Address - Street 2:SUITE 312
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1444
Mailing Address - Country:US
Mailing Address - Phone:847-827-0600
Mailing Address - Fax:877-481-0769
Practice Address - Street 1:1580 N NORTHWEST HWY
Practice Address - Street 2:SUITE 312
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1444
Practice Address - Country:US
Practice Address - Phone:847-827-0600
Practice Address - Fax:877-481-0769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490108611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty