Healthcare Provider Details

I. General information

NPI: 1770061822
Provider Name (Legal Business Name): RESTORING LIVES OVERCOMING ADDICTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11187 DUNDEE RD STE 101
HUNTLEY IL
60142-9246
US

IV. Provider business mailing address

10469 LANCASTER ST
HUNTLEY IL
60142-6793
US

V. Phone/Fax

Practice location:
  • Phone: 312-675-4205
  • Fax:
Mailing address:
  • Phone: 917-334-0420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY LLOYD COHAGEN
Title or Position: PRESIDENT
Credential:
Phone: 917-334-0420