Healthcare Provider Details

I. General information

NPI: 1073801452
Provider Name (Legal Business Name): OMEGA LASTER CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

IV. Provider business mailing address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-0205
  • Fax: 773-765-0842
Mailing address:
  • Phone: 773-769-0205
  • Fax: 773-765-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17601
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: