Healthcare Provider Details

I. General information

NPI: 1801309752
Provider Name (Legal Business Name): SAFER FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2839 W FILLMORE ST
CHICAGO IL
60612-4051
US

IV. Provider business mailing address

571 W JACKSON BLVD
CHICAGO IL
60661-5701
US

V. Phone/Fax

Practice location:
  • Phone: 773-638-8491
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.002611
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number180.002611
License Number StateIL

VIII. Authorized Official

Name: VICTOR DICKSON
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 312-922-4767