1801294418 NPI number — FIREFIGHTER BEHAVIORAL HEALTH OF ILLINOIS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801294418 NPI number — FIREFIGHTER BEHAVIORAL HEALTH OF ILLINOIS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIREFIGHTER BEHAVIORAL HEALTH OF ILLINOIS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801294418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1333 BURR RIDGE PKWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-6423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-557-1267
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1333 BURR RIDGE PKWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BURR RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60527-6423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-557-1267
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GURA
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
LICENSED CLINICAL PROFESSIONAL COUN
Authorized Official Telephone Number:
815-557-1267

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  180.007613 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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