Healthcare Provider Details

I. General information

NPI: 1205317377
Provider Name (Legal Business Name): AUTUMN HEALTHCARE OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9449 S KEDZIE AVE SUITE 142
EVERGREEN PK IL
60805-2325
US

IV. Provider business mailing address

9449 S KEDZIE AVE
EVERGREEN PK IL
60805-2325
US

V. Phone/Fax

Practice location:
  • Phone: 773-420-3481
  • Fax:
Mailing address:
  • Phone: 773-420-3481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES BROWN
Title or Position: OFFICE MANAGER
Credential:
Phone: 773-852-7454