Healthcare Provider Details

I. General information

NPI: 1255893939
Provider Name (Legal Business Name): SISTA AFYA COMMUNITY MENTAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 03/07/2021
Certification Date: 03/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 E 71ST ST
CHICAGO IL
60649-2000
US

IV. Provider business mailing address

503 E 61ST ST
CHICAGO IL
60637-2406
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-7994
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
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: CAMESHA LYNETTE JONES
Title or Position: LCSW/EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 773-234-7994