Provider Demographics
NPI:1437916962
Name:SURVIVORS CIRCLE
Entity Type:Organization
Organization Name:SURVIVORS CIRCLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:708-548-9209
Mailing Address - Street 1:PO BOX 973
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60079-0973
Mailing Address - Country:US
Mailing Address - Phone:708-548-9209
Mailing Address - Fax:
Practice Address - Street 1:150 S. GENESEE ST.
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:708-548-9209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or Welfare
No251V00000XAgenciesVoluntary or Charitable
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery CareGroup - Multi-Specialty
No374K00000XNursing Service Related ProvidersReligious Nonmedical PractitionerGroup - Multi-Specialty