Provider Demographics
NPI:1275771214
Name:MARYVILLE ACADEMY
Entity Type:Organization
Organization Name:MARYVILLE ACADEMY
Other - Org Name:CASA SALAMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:Z
Authorized Official - Last Name:WOULFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-294-1910
Mailing Address - Street 1:1150 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1214
Mailing Address - Country:US
Mailing Address - Phone:847-294-1999
Mailing Address - Fax:
Practice Address - Street 1:951 W BARTLETT RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4479
Practice Address - Country:US
Practice Address - Phone:630-736-7450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
IL008320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========008Medicaid