Healthcare Provider Details

I. General information

NPI: 1841995644
Provider Name (Legal Business Name): CHICAGO YOUTH SERVICE BUREAU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E 53RD ST
CHICAGO IL
60615-4557
US

IV. Provider business mailing address

1525 E 53RD ST
CHICAGO IL
60615-4557
US

V. Phone/Fax

Practice location:
  • Phone: 773-906-6690
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JESSICA PETTY
Title or Position: LPC
Credential:
Phone: 773-906-6690