Healthcare Provider Details

I. General information

NPI: 1578724738
Provider Name (Legal Business Name): HEARTLAND ALLIANCE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 N WINTHROP
CHICAGO IL
60640-7528
US

IV. Provider business mailing address

4750 N SHERIDAN RD STE 449
CHICAGO IL
60640-5078
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-1548
  • Fax: 773-506-1573
Mailing address:
  • Phone: 773-751-4129
  • Fax: 773-751-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number021
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: EDWARD STELLON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 773-751-4129