Organization
ILLINOIS MENTOR
Active
Parent organization
ILLINOIS MENTOR
Other names
Marion Site 014015
Organization subpart
Yes
Provider details
NPI number
Legal business name
ILLINOIS MENTOR
Authorized official
VIVIANE NGWA MSW (EXECUTIVE DIRECTOR)
(708) 679-9137
Entity
Organization
Contact information
Practice address
4503 W DEYOUNG ST, SUITE 203C, MARION, IL 62959-7654
(618) 997-9470
(618) 997-9478
Mailing address
4503 W DEYOUNG ST, SUITE 203C, MARION, IL 62959-7654
(618) 997-9470
(618) 997-9478
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
—
—
253J00000X
Foster Care Agency
Primary
—
—
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
—
—
Other
Enumeration date
11/30/2009
Last updated
11/30/2009
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