Provider Demographics
NPI:1932241627
Name:INSTITUTE FOR MOTIVATIONAL DEVELOPMENT OF ILLINOIS LTD
Entity Type:Organization
Organization Name:INSTITUTE FOR MOTIVATIONAL DEVELOPMENT OF ILLINOIS LTD
Other - Org Name:THE MARRIAGE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZEPEDA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:630-627-5000
Mailing Address - Street 1:10 E 22ND ST STE 210
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6108
Mailing Address - Country:US
Mailing Address - Phone:630-627-5000
Mailing Address - Fax:630-627-5032
Practice Address - Street 1:10 E 22ND ST STE 210
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6108
Practice Address - Country:US
Practice Address - Phone:630-627-5000
Practice Address - Fax:630-627-5032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2215154OtherBCBS OF ILLINOIS
IL953960Medicare ID - Type Unspecified