Provider Demographics
NPI:1669645040
Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity Type:Organization
Organization Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Other - Org Name:DIXON PRADER WILLI GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOONAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-635-4600
Mailing Address - Street 1:1001 E TOUHY AVE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-5801
Mailing Address - Country:US
Mailing Address - Phone:847-635-4600
Mailing Address - Fax:847-297-3407
Practice Address - Street 1:314 S OTTAWA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3150
Practice Address - Country:US
Practice Address - Phone:815-288-4108
Practice Address - Fax:815-288-2934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL926169320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL926169OtherDEPT OF HUMAN SERVICES