=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073418323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UCAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2026
-----------------------------------------------------
Last Update Date | 10/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1551 W 95TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-1329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-615-4787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3605 W FILLMORE ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60624-4310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-615-4787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF QI
-----------------------------------------------------
Name | TINA RUIZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-615-4787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------