Healthcare Provider Details

I. General information

NPI: 1497484331
Provider Name (Legal Business Name): LITTLE CITY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N SACRAMENTO BLVD
CHICAGO IL
60612-1046
US

IV. Provider business mailing address

303 W DIVISION ST APT 622
CHICAGO IL
60610-0343
US

V. Phone/Fax

Practice location:
  • Phone: 847-417-2092
  • Fax:
Mailing address:
  • Phone: 773-306-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE R. RAY
Title or Position: THERAPIST
Credential:
Phone: 773-306-3480