Provider Demographics
NPI:1023723392
Name:ALEXIAN BROTHERS BEHAVIORAL HEALTH HOSPITAL
Entity type:Organization
Organization Name:ALEXIAN BROTHERS BEHAVIORAL HEALTH HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR, NET REVENUE AND REIMB
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKNISKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-213-0776
Mailing Address - Street 1:1650 MOON LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-1010
Mailing Address - Country:US
Mailing Address - Phone:773-213-0776
Mailing Address - Fax:
Practice Address - Street 1:801 GLOUCESTER DR
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3319
Practice Address - Country:US
Practice Address - Phone:847-981-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALEXIAN BROTHERS BEHAVIORAL HEALTH HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA-9905-0003-AOtherSUPR LICENSE