Provider Demographics
NPI:1790143444
Name:SOJOURN HOUSE
Entity Type:Organization
Organization Name:SOJOURN HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CADC, MISA 1
Authorized Official - Phone:815-232-5121
Mailing Address - Street 1:565 N TURNER AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-3252
Mailing Address - Country:US
Mailing Address - Phone:815-232-5121
Mailing Address - Fax:815-233-4591
Practice Address - Street 1:565 N TURNER AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-3252
Practice Address - Country:US
Practice Address - Phone:815-232-5121
Practice Address - Fax:815-233-4591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0595-0001-A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility