Healthcare Provider Details

I. General information

NPI: 1639542681
Provider Name (Legal Business Name): MYSI CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 W 111TH ST SUITE 103
CHICAGO IL
60655-2240
US

IV. Provider business mailing address

3001 W 111TH ST SUITE 103
CHICAGO IL
60655-2240
US

V. Phone/Fax

Practice location:
  • Phone: 773-840-4600
  • Fax: 773-840-4606
Mailing address:
  • Phone: 773-840-4600
  • Fax: 773-840-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number15011
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number15011
License Number StateIL

VIII. Authorized Official

Name: MRS. TOLEDA HART
Title or Position: PRESIDENT/CEO
Credential:
Phone: 773-840-4600