Provider Demographics
NPI:1538338082
Name:UNIVERSITY OF ILLINOIS AT CHICAGO
Entity type:Organization
Organization Name:UNIVERSITY OF ILLINOIS AT CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, COIP
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:OUELLET
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-355-0145
Mailing Address - Street 1:1603 W. TAYLOR ST., M/C 923
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:312-996-1450
Practice Address - Street 1:1603 W TAYLOR ST
Practice Address - Street 2:M/C 923
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4310
Practice Address - Country:US
Practice Address - Phone:312-413-3210
Practice Address - Fax:312-996-1450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency