Provider Demographics
NPI:1417792284
Name:NOVA LUNA BEHAVIOR HEALTH SERVICES LLC
Entity type:Organization
Organization Name:NOVA LUNA BEHAVIOR HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRILLO-GUERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-615-5415
Mailing Address - Street 1:1653 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1309
Mailing Address - Country:US
Mailing Address - Phone:773-615-5415
Mailing Address - Fax:
Practice Address - Street 1:1653 W 35TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1309
Practice Address - Country:US
Practice Address - Phone:773-615-5415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health