Provider Demographics
NPI:1396954467
Name:ILLINOIS MENTOR
Entity type:Organization
Organization Name:ILLINOIS MENTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIVIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGWA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:708-679-9137
Mailing Address - Street 1:600 HOLIDAY PLAZA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-2241
Mailing Address - Country:US
Mailing Address - Phone:708-679-9137
Mailing Address - Fax:708-503-6267
Practice Address - Street 1:600 HOLIDAY PLAZA DR
Practice Address - Street 2:SUITE 400
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2241
Practice Address - Country:US
Practice Address - Phone:708-679-9137
Practice Address - Fax:708-503-6267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251B00000X, 320600000X
253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No251B00000XAgenciesCase Management
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities