Organization
ILLINOIS MENTOR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. VIVIANE NGWA MSW (EXECUTIVE DIRECTOR)
(708) 679-9137
Entity
Organization
Contact information
Practice address
600 HOLIDAY PLAZA DR, SUITE 400, MATTESON, IL 60443-2241
(708) 679-9137
(708) 503-6267
Mailing address
600 HOLIDAY PLAZA DR, SUITE 400, MATTESON, IL 60443-2241
(708) 679-9137
(708) 503-6267
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
—
IL
253J00000X
Foster Care Agency
Primary
—
—
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
—
IL
Other
Enumeration date
05/22/2007
Last updated
07/21/2022
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