Healthcare Provider Details

I. General information

NPI: 1588148548
Provider Name (Legal Business Name): FAMILY FIRST DOMESTIC & FAMILY COUNSELING CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9522 S HALSTED ST
CHICAGO IL
60628-1028
US

IV. Provider business mailing address

9522 S HALSTED ST
CHICAGO IL
60628-1028
US

V. Phone/Fax

Practice location:
  • Phone: 773-595-5794
  • Fax:
Mailing address:
  • Phone: 773-595-5794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JAMES BROWN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 773-852-7454