Provider Demographics
NPI:1386906139
Name:OPEN WINGS LEARNING COMMUNITY
Entity type:Organization
Organization Name:OPEN WINGS LEARNING COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-587-1742
Mailing Address - Street 1:778 W FRONTAGE RD
Mailing Address - Street 2:STE. 123
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1209
Mailing Address - Country:US
Mailing Address - Phone:312-587-1742
Mailing Address - Fax:312-376-1047
Practice Address - Street 1:778 W FRONTAGE RD
Practice Address - Street 2:STE. 123
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1209
Practice Address - Country:US
Practice Address - Phone:312-587-1742
Practice Address - Fax:312-376-1047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006306261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health