Provider Demographics
NPI:1942453048
Name:INDIVIDUAL ADVOCACY GROUP
Entity Type:Organization
Organization Name:INDIVIDUAL ADVOCACY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:630-759-0201
Mailing Address - Street 1:1289 WINDHAM PKWY
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-1763
Mailing Address - Country:US
Mailing Address - Phone:630-759-0201
Mailing Address - Fax:630-759-1005
Practice Address - Street 1:1289 WINDHAM PKWY
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-1763
Practice Address - Country:US
Practice Address - Phone:630-759-0201
Practice Address - Fax:630-759-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251C00000X, 251J00000X, 253Z00000X, 261QD1600X, 261QM0850X, 320900000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========100Medicaid