Healthcare Provider Details

I. General information

NPI: 1356070874
Provider Name (Legal Business Name): THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/09/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 W ROOSEVELT RD
CHICAGO IL
60608-1316
US

IV. Provider business mailing address

5254 SOLUTION CENTER UIC BEHAVIORAL HEALTH CLINIC
CHICAGO IL
60677-0001
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-8043
  • Fax: 312-413-8333
Mailing address:
  • Phone: 312-996-1000
  • Fax: 312-996-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ABRIANNA CUMMINGS
Title or Position: LEAD CREDENTIALING SPECIALIST
Credential:
Phone: 773-757-4364