Healthcare Provider Details

I. General information

NPI: 1972234730
Provider Name (Legal Business Name): UCP SEGUIN OF GREATER CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 W ARMITAGE CT
ADDISON IL
60101-4207
US

IV. Provider business mailing address

3100 S CENTRAL AVE
CICERO IL
60804-3956
US

V. Phone/Fax

Practice location:
  • Phone: 708-863-3803
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DONNA RESSLER ROBINSON
Title or Position: CLINICAL SERVICES ADMINISTRATOR
Credential:
Phone: 708-222-4607