Healthcare Provider Details

I. General information

NPI: 1689100356
Provider Name (Legal Business Name): CHICAGO TREATMENT & COUNSELING CENTER #2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4453 N BROADWAY ST
CHICAGO IL
60640-5659
US

IV. Provider business mailing address

4453 N BROADWAY ST
CHICAGO IL
60640-5659
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-2900
  • Fax: 773-506-8987
Mailing address:
  • Phone: 773-506-2900
  • Fax: 773-506-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0360699638
License Number StateIL

VIII. Authorized Official

Name: HEMLATA VAIDYA
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 708-656-9500