Healthcare Provider Details

I. General information

NPI: 1578687620
Provider Name (Legal Business Name): COMMUNITY COUNSELING CENTERS OF CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 N BROADWAY ST
CHICAGO IL
60660-4302
US

IV. Provider business mailing address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

V. Phone/Fax

Practice location:
  • Phone: 773-728-1000
  • Fax: 773-765-0401
Mailing address:
  • Phone: 773-769-0205
  • Fax: 773-765-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number04029
License Number StateIL

VIII. Authorized Official

Name: DR. ANTHONY A KOPERA
Title or Position: PRESIDENT &C.E.O.
Credential: PHD
Phone: 773-769-0205