Provider Demographics
NPI:1669827580
Name:GUILDHAUS
Entity Type:Organization
Organization Name:GUILDHAUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:LAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-385-3228
Mailing Address - Street 1:13315 OLDE WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2921
Mailing Address - Country:US
Mailing Address - Phone:708-926-9627
Mailing Address - Fax:
Practice Address - Street 1:13315 OLDE WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2921
Practice Address - Country:US
Practice Address - Phone:708-926-9627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUILDHAUS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0991-0004-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health