Healthcare Provider Details

I. General information

NPI: 1295154813
Provider Name (Legal Business Name): CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date: 05/12/2023
Reactivation Date: 12/28/2023

III. Provider practice location address

671 S LEWIS AVE
WAUKEGAN IL
60085-6101
US

IV. Provider business mailing address

671 S LEWIS AVE
WAUKEGAN IL
60085-6101
US

V. Phone/Fax

Practice location:
  • Phone: 847-782-4154
  • Fax: 847-782-1030
Mailing address:
  • Phone: 847-782-4154
  • Fax: 847-782-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number04019
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELLEN TANNENBAUM
Title or Position: DIRECTOR BEHAVIORAL HEALTH
Credential:
Phone: 773-551-3067