Provider Demographics
NPI:1720258619
Name:AUNT MARTHA'S YOUTH SERVICE CENTER
Entity Type:Organization
Organization Name:AUNT MARTHA'S YOUTH SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:NORDLOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-747-7100
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:
Practice Address - Street 1:15020 CICERO AVE
Practice Address - Street 2:SUITE D
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-1441
Practice Address - Country:US
Practice Address - Phone:708-535-2934
Practice Address - Fax:708-535-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health