Provider Demographics
NPI:1467909275
Name:MARYVILLE ACADEMY
Entity Type:Organization
Organization Name:MARYVILLE ACADEMY
Other - Org Name:FAMILY BEHAVIORAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SR. CATHERINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-294-1893
Mailing Address - Street 1:701 LEE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4543
Mailing Address - Country:US
Mailing Address - Phone:847-390-3004
Mailing Address - Fax:847-390-3016
Practice Address - Street 1:701 LEE ST STE 100
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4543
Practice Address - Country:US
Practice Address - Phone:847-390-3004
Practice Address - Fax:847-390-3016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-09
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QM0855X, 261QR0405X
IL261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder