Healthcare Provider Details

I. General information

NPI: 1568828291
Provider Name (Legal Business Name): DEBORAH'S PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2822 W JACKSON BLVD
CHICAGO IL
60612-3653
US

IV. Provider business mailing address

1456 W OAKDALE AVE
CHICAGO IL
60657-4119
US

V. Phone/Fax

Practice location:
  • Phone: 773-722-5080
  • Fax:
Mailing address:
  • Phone: 773-348-9011
  • Fax: 773-348-9058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number149.007559
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number149.011208
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number149.016615
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number149.015965
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number150.015350
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number149.007559
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number149.011208
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number149.016615
License Number StateIL
# 9
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number149.015965
License Number StateIL
# 10
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number150.015350
License Number StateIL

VIII. Authorized Official

Name: MS. KATHARINE C BOOTON WILSON
Title or Position: CHIEF STRATEGY OFFICER
Credential: LCSW
Phone: 773-638-6392