Organization
LUTHERAN SOCIAL SERVICES OF ILLINOIS
Active
Other names
Portage Cragin Outpatient
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MARK STUTRUD (PRESIDENT)
(847) 635-4600
Entity
Organization
Contact information
Practice address
4840 W BYRON ST, CHICAGO, IL 60641-2712
(773) 282-7800
(773) 282-2163
Mailing address
1001 E TOUHY AVE STE 50, DES PLAINES, IL 60018-5817
(847) 635-4600
(847) 297-3407
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
—
—
1041C0700X
Clinical Social Worker
—
—
207Q00000X
Family Medicine Physician
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0001618748
BLUE CROSS BLUE SHIELD
IL
Enumeration date
04/17/2007
Last updated
12/31/2019
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