Provider Demographics
NPI:1609224328
Name:ST. MARY OF PROVIDENCE DEVELOPMENTAL TRAINING PROGRAM
Entity Type:Organization
Organization Name:ST. MARY OF PROVIDENCE DEVELOPMENTAL TRAINING PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BADIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-545-8300
Mailing Address - Street 1:4200 N AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1615
Mailing Address - Country:US
Mailing Address - Phone:773-545-8300
Mailing Address - Fax:
Practice Address - Street 1:4200 N AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-1615
Practice Address - Country:US
Practice Address - Phone:773-545-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY OF PROVIDENCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36217748251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14G191Medicaid