Provider Demographics
NPI:1518905173
Name:MARYVILLE ACADEMY
Entity Type:Organization
Organization Name:MARYVILLE ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:NORM
Authorized Official - Middle Name:
Authorized Official - Last Name:JOYCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-294-1944
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:847-294-2892
Practice Address - Street 1:555 WILSON LN
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4729
Practice Address - Country:US
Practice Address - Phone:847-768-5461
Practice Address - Fax:847-768-5478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1702101283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========012Medicaid