Healthcare Provider Details

I. General information

NPI: 1699864017
Provider Name (Legal Business Name): BETTY J THOMAS CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2332 S 22ND AVE
BROADVIEW IL
60155-3805
US

IV. Provider business mailing address

2332 S 22ND AVE
BROADVIEW IL
60155-3805
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-3652
  • Fax: 708-202-7013
Mailing address:
  • Phone: 708-202-3652
  • Fax: 708-202-7013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6068
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: