MEDICARE: LEYDEN FAMILY SERVICE & MENTAL HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	04089	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01618936	OTHER	IL	BLUE CROSS/BLUE SHIELD ID

General Provider Information

NPI Number	:	1023102712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEYDEN FAMILY SERVICE & MENTAL HEALTH CENTER

Provider Business Mailing Address
First Line	:	4600 N. HARLEM
Second Line	:
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706
Country	:	US
Telephone Number	:	708-867-6886
Fax Number	:

Provider Business Practice Location Address
First Line	:	4600 N. HARLEM
Second Line	:
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706
Country	:	US
Telephone Number	:	708-867-6886
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	MRS. DOONA CHIARIELLO SANTORO
Credential	:	MSW, LCSW
Telephone Number	:	847-843-4919

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	08/22/2020

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