Healthcare Provider Details

I. General information

NPI: 1962657585
Provider Name (Legal Business Name): FOR THE CAUSE STI AWARENESS CHARITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 HASSELL RD
HOFFMAN ESTATES IL
60169-2148
US

IV. Provider business mailing address

2200 HASSELL RD
HOFFMAN ESTATES IL
60169-2148
US

V. Phone/Fax

Practice location:
  • Phone: 847-802-8133
  • Fax:
Mailing address:
  • Phone: 847-802-8133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1085631
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number45175811
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number45175811
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number45175811
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number45175811
License Number StateIL

VIII. Authorized Official

Name: MRS. OCTAVIA JARE'L COLEMAN
Title or Position: FOUNDER/COUNSELOR
Credential: MHSA
Phone: 919-455-3740