Provider Demographics
NPI:1013294271
Name:ARDEN SHORE CHILD AND FAMILY SERVICES
Entity type:Organization
Organization Name:ARDEN SHORE CHILD AND FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-623-1730
Mailing Address - Street 1:329 N GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-4205
Mailing Address - Country:US
Mailing Address - Phone:847-623-1730
Mailing Address - Fax:847-623-1733
Practice Address - Street 1:329 N GENESEE ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4205
Practice Address - Country:US
Practice Address - Phone:847-623-1730
Practice Address - Fax:847-623-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 253J00000X, 251S00000X
IL31414206322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No253J00000XAgenciesFoster Care Agency
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children