Healthcare Provider Details

I. General information

NPI: 1699388181
Provider Name (Legal Business Name): BOBBY E. WRIGHT COMPREHENSIVE BEHAVIORAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5816 W DIVISION ST FL 1
CHICAGO IL
60651-1003
US

IV. Provider business mailing address

5002 W MADISON ST
CHICAGO IL
60644-4127
US

V. Phone/Fax

Practice location:
  • Phone: 773-722-7900
  • Fax: 773-722-0644
Mailing address:
  • Phone: 773-722-7900
  • Fax: 773-722-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SIMONE EDWARDS
Title or Position: CFO
Credential:
Phone: 773-722-7900