Healthcare Provider Details

I. General information

NPI: 1013228717
Provider Name (Legal Business Name): COUNSELING CENTER OF LAKEVIEW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 N SHEFFIELD AVE
CHICAGO IL
60657-2210
US

IV. Provider business mailing address

3225 N SHEFFIELD AVE
CHICAGO IL
60657-2210
US

V. Phone/Fax

Practice location:
  • Phone: 773-549-5886
  • Fax: 773-549-5892
Mailing address:
  • Phone: 773-549-5886
  • Fax: 773-549-5892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number180.004932
License Number StateIL

VIII. Authorized Official

Name: MR. JAMES JOHN CHRYSTAL JR.
Title or Position: CASEWORKER 4
Credential: L.C.P.C.
Phone: 773-549-5886