Healthcare Provider Details

I. General information

NPI: 1831367036
Provider Name (Legal Business Name): BOBBY E WRIGHT CCMHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 W JACKSON BLVD
CHICAGO IL
60624-3255
US

IV. Provider business mailing address

5002 W MADISON ST
CHICAGO IL
60644-4127
US

V. Phone/Fax

Practice location:
  • Phone: 773-722-7900
  • Fax: 773-722-0644
Mailing address:
  • Phone: 773-722-7900
  • Fax: 773-722-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SIMONE EDWARDS
Title or Position: CFO
Credential:
Phone: 773-722-7900