Provider Demographics
NPI:1306873419
Name:MARYVILLE ACADEMY
Entity type:Organization
Organization Name:MARYVILLE ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:Z
Authorized Official - Last Name:WOULFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-294-1910
Mailing Address - Street 1:1150 N RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1290
Mailing Address - Country:US
Mailing Address - Phone:847-294-1999
Mailing Address - Fax:847-294-2892
Practice Address - Street 1:555 WILSON LANE
Practice Address - Street 2:MARYVILLE SCOTT NOLAN CENTER
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4729
Practice Address - Country:US
Practice Address - Phone:847-768-5461
Practice Address - Fax:847-768-5478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========011Medicaid