Provider Demographics
NPI:1487993580
Name:ACTIVE VISIONS, INC.
Entity type:Organization
Organization Name:ACTIVE VISIONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QIDP, QMHP
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:FARRELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:773-594-0921
Mailing Address - Street 1:6416 N LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-2704
Mailing Address - Country:US
Mailing Address - Phone:773-594-0921
Mailing Address - Fax:773-594-1238
Practice Address - Street 1:6416 N LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-2704
Practice Address - Country:US
Practice Address - Phone:773-594-0921
Practice Address - Fax:773-594-1238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.010895251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health