Healthcare Provider Details

I. General information

NPI: 1083316392
Provider Name (Legal Business Name): JUST A MILE AWAY MENTAL HEALTH SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/23/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 W. TAYLOR ST
CHICAGO IL
60607-0000
US

IV. Provider business mailing address

PO BOX 440312
CHICAGO IL
60644-0306
US

V. Phone/Fax

Practice location:
  • Phone: 708-775-2825
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TATIANA LANE
Title or Position: CEO
Credential:
Phone: 708-775-2825