Healthcare Provider Details

I. General information

NPI: 1205652419
Provider Name (Legal Business Name): UNITED AGAINST VIOLENCE, NFP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6636 S YALE AVE
CHICAGO IL
60621-3836
US

IV. Provider business mailing address

6636 S YALE AVE
CHICAGO IL
60621-3836
US

V. Phone/Fax

Practice location:
  • Phone: 773-619-7247
  • Fax:
Mailing address:
  • Phone: 773-619-7247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KENYATTA VAUGHN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 773-619-7247