Healthcare Provider Details

I. General information

NPI: 1932414000
Provider Name (Legal Business Name): COUNSELING CENTER OF LAKE VIEW - SUBSTANCE ABUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 N SHEFFIELD AVE
CHICAGO IL
60657-2210
US

IV. Provider business mailing address

3225 N SHEFFIELD AVE
CHICAGO IL
60657-2210
US

V. Phone/Fax

Practice location:
  • Phone: 773-549-5886
  • Fax: 773-549-3265
Mailing address:
  • Phone: 773-549-5886
  • Fax: 773-549-3265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberA0127-0001-A
License Number StateIL

VIII. Authorized Official

Name: MR. GEORGE JAMES CURTISS
Title or Position: CONTROLLER
Credential:
Phone: 773-549-1102