Provider Demographics
NPI:1679907463
Name:MIDWAY MEDIATION & COACHING SERVICES, LLC
Entity Type:Organization
Organization Name:MIDWAY MEDIATION & COACHING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-852-0499
Mailing Address - Street 1:1160 STARWOOD PASS
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-4890
Mailing Address - Country:US
Mailing Address - Phone:847-852-0499
Mailing Address - Fax:815-477-2270
Practice Address - Street 1:610 CRYSTAL POINT DR
Practice Address - Street 2:SUITE 3
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-1401
Practice Address - Country:US
Practice Address - Phone:847-852-0499
Practice Address - Fax:815-477-2287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490114031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty