Healthcare Provider Details

I. General information

NPI: 1114242112
Provider Name (Legal Business Name): CHILDHOOD TRAUMA TREATMENT PROGRAM OF ADVOCATE HEALTH & HOSPITALS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 W 95TH ST STE LL5
OAK LAWN IL
60453-2575
US

IV. Provider business mailing address

PO BOX 776 CHILDHOOD TRAUMA TREATMENT PROGRAM
OAK LAWN IL
60454-0776
US

V. Phone/Fax

Practice location:
  • Phone: 800-216-1110
  • Fax: 708-346-4868
Mailing address:
  • Phone: 800-216-1110
  • Fax: 708-346-4868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SARA SKINNER
Title or Position: CLINICAL MANAGER
Credential: PSY.D
Phone: 800-216-1110