Healthcare Provider Details

I. General information

NPI: 1891486742
Provider Name (Legal Business Name): ALEXIAN BROTHERS CENTER FOR MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3436 N KENNICOTT AVE
ARLINGTON HEIGHTS IL
60004-7814
US

IV. Provider business mailing address

3436 N KENNICOTT AVE
ARLINGTON HEIGHTS IL
60004-7814
US

V. Phone/Fax

Practice location:
  • Phone: 847-952-7460
  • Fax:
Mailing address:
  • Phone: 847-952-7460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: MARY JO MACKNISKAS
Title or Position: SR. DIRECTOR NET REVENUE AND REIMB
Credential:
Phone: 773-213-0776