Provider Demographics
NPI:1104235415
Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity type:Organization
Organization Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
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# 170
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-5801
Mailing Address - Country:US
Mailing Address - Phone:847-390-1422
Mailing Address - Fax:847-297-3407
Practice Address - Street 1:1901 1ST AVE
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1203
Practice Address - Country:US
Practice Address - Phone:815-626-7333
Practice Address - Fax:815-626-8752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490157401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149015740OtherSTATE LICENSE