Healthcare Provider Details

I. General information

NPI: 1346732989
Provider Name (Legal Business Name): ENVISION UNLIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4828 W CORNELIA AVE
CHICAGO IL
60641
US

IV. Provider business mailing address

5080 N ELSTON AVE
CHICAGO IL
60630-2459
US

V. Phone/Fax

Practice location:
  • Phone: 773-676-2123
  • Fax:
Mailing address:
  • Phone: 773-506-3201
  • Fax: 773-769-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number18004
License Number StateIL

VIII. Authorized Official

Name: LINDA A BRUGGEMANN
Title or Position: BILLING COORDINATOR
Credential: LPC
Phone: 773-506-3201