Healthcare Provider Details

I. General information

NPI: 1053108456
Provider Name (Legal Business Name): LIFEHOUSE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14127 LEAVITT AVE
BLUE ISLAND IL
60406-3242
US

IV. Provider business mailing address

14127 LEAVITT AVE
BLUE ISLAND IL
60406-3242
US

V. Phone/Fax

Practice location:
  • Phone: 708-897-8581
  • Fax:
Mailing address:
  • Phone: 708-897-8581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL EDWARD WALSH
Title or Position: CEO
Credential: NCRS
Phone: 312-451-5996