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? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 101YP1600X | Behavioral Health & Social Service Providers | Counselor | Pastoral | |
No | 101YS0200X | Behavioral Health & Social Service Providers | Counselor | School | Group - Multi-Specialty |
No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
No | 103TR0400X | Behavioral Health & Social Service Providers | Psychologist | Rehabilitation | Group - Multi-Specialty |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 251K00000X | Agencies | Public Health or Welfare | ||
No | 251V00000X | Agencies | Voluntary or Charitable | ||
No | 261QC1500X | Ambulatory Health Care Facilities | Clinic/Center | Community Health | |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | |
No | 261QP0905X | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local | |
No | 261QP2400X | Ambulatory Health Care Facilities | Clinic/Center | Prison Health | |
No | 261QR0800X | Ambulatory Health Care Facilities | Clinic/Center | Recovery Care | Group - Multi-Specialty |
No | 374K00000X | Nursing Service Related Providers | Religious Nonmedical Practitioner | Group - Multi-Specialty |