Provider Demographics
NPI:1972705192
Name:AUNT MARTHA'S YOUTH SERVICE CENTER
Entity Type:Organization
Organization Name:AUNT MARTHA'S YOUTH SERVICE CENTER
Other - Org Name:AUNT MARTHA'S ADAPT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-825-5976
Mailing Address - Street 1:19990 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1021
Mailing Address - Country:US
Mailing Address - Phone:708-747-7100
Mailing Address - Fax:708-747-0710
Practice Address - Street 1:1777 E COURT ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2670
Practice Address - Country:US
Practice Address - Phone:815-937-5413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid