Healthcare Provider Details

I. General information

NPI: 1225364078
Provider Name (Legal Business Name): LITTLE CITY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N SACRAMENTO BLVD
CHICAGO IL
60612-1046
US

IV. Provider business mailing address

700 N SACRAMENTO BLVD
CHICAGO IL
60612-1046
US

V. Phone/Fax

Practice location:
  • Phone: 773-265-2539
  • Fax: 773-265-1755
Mailing address:
  • Phone: 773-265-2539
  • Fax: 773-265-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number3B00-IPI-053
License Number StateIL

VIII. Authorized Official

Name: SHAWN JEFFERS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 847-358-5510