Healthcare Provider Details

I. General information

NPI: 1568287928
Provider Name (Legal Business Name): COMMUNITY SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9021 OGDEN AVE
BROOKFIELD IL
60513-2040
US

IV. Provider business mailing address

9021 OGDEN AVE
BROOKFIELD IL
60513-2040
US

V. Phone/Fax

Practice location:
  • Phone: 708-354-4785
  • Fax: 708-354-7412
Mailing address:
  • Phone: 708-354-4785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN EDGAR MIHELIC
Title or Position: DIRECTOR, DATA ANALYTICS
Credential:
Phone: 708-354-4547