Healthcare Provider Details

I. General information

NPI: 1588810550
Provider Name (Legal Business Name): PROVISO FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

100 N RIVER RD
DES PLAINES IL
60016-1209
US

IV. Provider business mailing address

1820 S 25TH AVE
BROADVIEW IL
60155-2864
US

V. Phone/Fax

Practice location:
  • Phone: 708-338-3806
  • Fax: 708-681-1289
Mailing address:
  • Phone: 708-338-3806
  • Fax: 708-681-1289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. KRISTIN KAMISKI
Title or Position: MANAGER, GENERAL ACCOUNTING
Credential:
Phone: 708-338-3806