Provider Demographics
NPI:1831300847
Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity Type:Organization
Organization Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Other - Org Name:BHS PROJECT SAFE
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
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 1:1764 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1130
Practice Address - Country:US
Practice Address - Phone:773-764-4512
Practice Address - Fax:773-764-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0286-0004-A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========049Medicaid