Healthcare Provider Details

I. General information

NPI: 1144577321
Provider Name (Legal Business Name): LITTLE CITY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 W ALGONQUIN RD
PALATINE IL
60067-4791
US

IV. Provider business mailing address

1760 W ALGONQUIN RD
PALATINE IL
60067-4791
US

V. Phone/Fax

Practice location:
  • Phone: 847-358-5510
  • Fax: 847-358-3296
Mailing address:
  • Phone: 847-358-5510
  • Fax: 847-358-3296

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
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number012633
License Number StateIL

VIII. Authorized Official

Name: SHAWN JEFFERS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 847-221-7860