Provider Demographics
NPI:1750334447
Name:LUTHERAN SOCIAL SERVICES OF IL
Entity type:Organization
Organization Name:LUTHERAN SOCIAL SERVICES OF IL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. FINANCE / CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:NOONAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-635-4600
Mailing Address - Street 1:1001 E TOUHY AVE
Mailing Address - Street 2:SUITE 50
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-5801
Mailing Address - Country:US
Mailing Address - Phone:847-635-4600
Mailing Address - Fax:847-635-6764
Practice Address - Street 1:1616 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1146
Practice Address - Country:US
Practice Address - Phone:618-997-9196
Practice Address - Fax:618-997-6843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL027261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04092Medicaid