Healthcare Provider Details

I. General information

NPI: 1295195295
Provider Name (Legal Business Name): ST. COLETTA'S OF ILLINOIS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18350 CROSSING DR
TINLEY PARK IL
60487-6294
US

IV. Provider business mailing address

18350 CROSSING DR
TINLEY PARK IL
60487-6294
US

V. Phone/Fax

Practice location:
  • Phone: 708-342-5200
  • Fax:
Mailing address:
  • Phone: 708-342-5200
  • Fax: 708-342-2579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number199100115C
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number199100115C
License Number StateIL

VIII. Authorized Official

Name: MRS. ANNETTE SKAFGAARD
Title or Position: VICE PRESIDENT OF FINANCE & OPERATI
Credential:
Phone: 708-342-5253