Provider Demographics
NPI:1396073565
Name:ILLINOIS MENTOR
Entity type:Organization
Organization Name:ILLINOIS MENTOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIVIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGWA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:708-679-9137
Mailing Address - Street 1:6701 CLINTON RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3863
Mailing Address - Country:US
Mailing Address - Phone:815-282-6153
Mailing Address - Fax:815-282-7160
Practice Address - Street 1:6701 CLINTON RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3863
Practice Address - Country:US
Practice Address - Phone:815-282-6153
Practice Address - Fax:815-282-7160
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINOIS MENTOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No251B00000XAgenciesCase Management
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities