Healthcare Provider Details

I. General information

NPI: 1720784572
Provider Name (Legal Business Name): COMMUNITY COUNSELING CENTERS OF CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2023
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2542 W NORTH AVE
CHICAGO IL
60647-5216
US

IV. Provider business mailing address

2014 W BELLE PLAINE AVE
CHICAGO IL
60618-3002
US

V. Phone/Fax

Practice location:
  • Phone: 773-365-7277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: KELLY DAVIS
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 872-235-0258