Healthcare Provider Details

I. General information

NPI: 1245528710
Provider Name (Legal Business Name): BEACON THERAPEUTIC SCHOOL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11740 S WESTERN AVE
CHICAGO IL
60643-4732
US

IV. Provider business mailing address

10650 S LONGWOOD DR
CHICAGO IL
60643-2617
US

V. Phone/Fax

Practice location:
  • Phone: 773-233-3821
  • Fax: 773-298-1078
Mailing address:
  • Phone: 773-881-1005
  • Fax: 773-881-1164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number04011
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number04011
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateIL

VIII. Authorized Official

Name: MS. CHERYL THOMPSON
Title or Position: DEPUTY CEO
Credential:
Phone: 773-298-1243