MEDICARE: COMMUNITY COUNSELING CENTERS OF CHICAGO

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)	04029	IL

General Provider Information

NPI Number	:	1578687620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY COUNSELING CENTERS OF CHICAGO

Provider Business Mailing Address
First Line	:	4740 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-4689
Country	:	US
Telephone Number	:	773-769-0205
Fax Number	:	773-765-0801

Provider Business Practice Location Address
First Line	:	5710 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-4302
Country	:	US
Telephone Number	:	773-728-1000
Fax Number	:	773-765-0401

Authorized Official
Title or Position	:	PRESIDENT &C.E.O.
Name	:	DR. ANTHONY A KOPERA
Credential	:	PHD
Telephone Number	:	773-769-0205

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	04/20/2008

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