Healthcare Provider Details

I. General information

NPI: 1679009880
Provider Name (Legal Business Name): CHICAGO TREATMENT & COUNSELING CENTER #4
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 W ROOSEVELT RD
CICERO IL
60804-1230
US

IV. Provider business mailing address

5635 W ROOSEVELT RD
CICERO IL
60804-1230
US

V. Phone/Fax

Practice location:
  • Phone: 708-652-6500
  • Fax: 708-652-6475
Mailing address:
  • Phone: 708-652-6500
  • Fax: 708-652-6475

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 Number036069638
License Number StateIL

VIII. Authorized Official

Name: HEMLATA VAIDYA
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 708-652-6500