Provider Demographics
NPI:1548579790
Name:MARYVILLE ACADEMY
Entity Type:Organization
Organization Name:MARYVILLE ACADEMY
Other - Org Name:ST. MARTIN DE PORRIS
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:Z
Authorized Official - Last Name:WOULFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-294-1910
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 1:1150 N RIVER RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1214
Practice Address - Country:US
Practice Address - Phone:847-294-1999
Practice Address - Fax:847-294-2892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness