Healthcare Provider Details

I. General information

NPI: 1710398904
Provider Name (Legal Business Name): ST MICHAELS COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2014
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7124 W GRAND AVE
CHICAGO IL
60707-2805
US

IV. Provider business mailing address

7124 W GRAND AVE
CHICAGO IL
60707-2805
US

V. Phone/Fax

Practice location:
  • Phone: 773-598-8540
  • Fax:
Mailing address:
  • Phone: 773-598-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberA-8254-0001-A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberA-8254-0001-A
License Number StateIL

VIII. Authorized Official

Name: DR. GEORGE SIANIS
Title or Position: OWNER
Credential: M.D.
Phone: 773-598-8540