Healthcare Provider Details

I. General information

NPI: 1881911543
Provider Name (Legal Business Name): HEPHZIBAH CHILDREN'S ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 LAKE ST 5TH FLOOR
OAK PARK IL
60301-6705
US

IV. Provider business mailing address

1144 LAKE ST FL 5
OAK PARK IL
60301-6706
US

V. Phone/Fax

Practice location:
  • Phone: 708-649-7140
  • Fax: 708-649-7194
Mailing address:
  • Phone: 708-649-7140
  • Fax: 708-649-7194

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: MS. MERRY BETH SHEETS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 708-649-7100