Healthcare Provider Details

I. General information

NPI: 1700086477
Provider Name (Legal Business Name): SUCCESS CENTER INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 BERNICE RD
LANSING IL
60438-1040
US

IV. Provider business mailing address

2755 BERNICE RD
LANSING IL
60438-1040
US

V. Phone/Fax

Practice location:
  • Phone: 708-474-7601
  • Fax: 708-474-7615
Mailing address:
  • Phone: 708-474-7601
  • Fax: 708-474-7615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLY ANOE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 708-474-7601