Provider Demographics
NPI:1003341058
Name:MARYVILLE ACADEMY
Entity type:Organization
Organization Name:MARYVILLE ACADEMY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:Z
Authorized Official - Last Name:WOULFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-294-1910
Mailing Address - Street 1:1658 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-6309
Mailing Address - Country:US
Mailing Address - Phone:312-491-3530
Mailing Address - Fax:
Practice Address - Street 1:1658 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-6309
Practice Address - Country:US
Practice Address - Phone:312-491-3530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder