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General NPI Number Information
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NPI Number | 1093423790
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Entity Type | Organization
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Legal Business Name | CHICAGO MENTAL AND LIFE WELLNESS INSTITUTE
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Dates
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Enumeration Date | 11/10/2022
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Last Update Date | 05/12/2023
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Provider Practice Location Address
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Address Line | 8547 S STONY ISLAND AVE
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City | CHICAGO
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State | IL
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Zip | 60617-2249
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Country | US
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Telephone | 773-569-0791
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Fax |
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Provider Business Mailing Address
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Address Line | 3817 W 85TH PL
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City | CHICAGO
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State | IL
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Zip | 60652-3709
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Country | US
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Telephone | 773-569-0791
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TANISHA HINES
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Credential |
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Telephone | 773-569-0791
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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