Healthcare Provider Details

I. General information

NPI: 1396671830
Provider Name (Legal Business Name): THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 W ROOSEVELT RD # MC727
CHICAGO IL
60608-1316
US

IV. Provider business mailing address

1640 W ROOSEVELT RD # MC727
CHICAGO IL
60608-1316
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-2652
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY THERESE KEEHN
Title or Position: ASSOC DEAN FOR CLINICAL AFFAIRS - C
Credential:
Phone: 312-413-2873