Healthcare Provider Details

I. General information

NPI: 1740438613
Provider Name (Legal Business Name): ASSOCIATION HOUSE OF CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 N. KEDZIE
CHICAGO IL
60651
US

IV. Provider business mailing address

1116 N. KEDZIE
CHICAGO IL
60651
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-7170
  • Fax: 773-384-0560
Mailing address:
  • Phone: 773-772-7170
  • Fax: 773-384-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA-0102-0001-A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. HARRIET SADAUSKAS
Title or Position: PRESIDENT
Credential:
Phone: 773-772-7170