Provider Demographics
NPI:1407014046
Name:AUNT MARTHA'S YOUTH SERVICE CENTER, INC
Entity Type:Organization
Organization Name:AUNT MARTHA'S YOUTH SERVICE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:NORDLOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-747-7100
Mailing Address - Street 1:19990 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1021
Mailing Address - Country:US
Mailing Address - Phone:708-747-7100
Mailing Address - Fax:
Practice Address - Street 1:1515 LAKE ST
Practice Address - Street 2:
Practice Address - City:HANOVER PARK
Practice Address - State:IL
Practice Address - Zip Code:60133-4896
Practice Address - Country:US
Practice Address - Phone:708-747-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========049Medicaid
141123Medicare Oscar/Certification