Provider Demographics
NPI:1891226767
Name:NORTH SHORE RESILIENT FAMILY LLC
Entity type:Organization
Organization Name:NORTH SHORE RESILIENT FAMILY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARY ALEXANDRA 'ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-461-9731
Mailing Address - Street 1:2636 PRAIRIE AVE APT A
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5743
Mailing Address - Country:US
Mailing Address - Phone:847-461-9731
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST STE 416
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4580
Practice Address - Country:US
Practice Address - Phone:847-461-9731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0090181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherN/A
00000000OtherN/A