Healthcare Provider Details

I. General information

NPI: 1669690038
Provider Name (Legal Business Name): CHICAGO LIGHTHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 W ROOSEVELT RD
CHICAGO IL
60608-1228
US

IV. Provider business mailing address

1850 W ROOSEVELT RD
CHICAGO IL
60608-1228
US

V. Phone/Fax

Practice location:
  • Phone: 312-666-1331
  • Fax: 312-506-0103
Mailing address:
  • Phone: 312-666-1331
  • Fax: 312-506-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARY ZABELSKI
Title or Position: DIRECTOR OF CHILCREN SERVICES
Credential:
Phone: 312-666-1331