Healthcare Provider Details

I. General information

NPI: 1255443669
Provider Name (Legal Business Name): OUTREACH COMMUNITY MINISTRIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W LIBERTY DR
WHEATON IL
60187-5124
US

IV. Provider business mailing address

373 S SCHMALE RD STE 102
CAROL STREAM IL
60188-2771
US

V. Phone/Fax

Practice location:
  • Phone: 630-682-1910
  • Fax: 630-682-0655
Mailing address:
  • Phone: 630-682-1910
  • Fax: 630-682-3094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02232105
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name: BRIAN T. LUX
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: LCPC
Phone: 630-682-1910