Healthcare Provider Details

I. General information

NPI: 1063497345
Provider Name (Legal Business Name): PALOS PSYCHIATRIC & RECOVERY INST LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 W COLLEGE DR 101
PALOS HEIGHTS IL
60463-1152
US

IV. Provider business mailing address

7300 W COLLEGE DR SUITE 101
PALOS HEIGHTS IL
60463-1152
US

V. Phone/Fax

Practice location:
  • Phone: 708-448-8470
  • Fax: 708-448-9651
Mailing address:
  • Phone: 708-448-8470
  • Fax: 708-448-9651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18000637
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. DALIA COLLAZO
Title or Position: INS COORDINATOR
Credential:
Phone: 708-448-8470