=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093954075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SGA YOUTH & FAMILY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2009
-----------------------------------------------------
Last Update Date | 10/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3152 W 47TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-321-9019
-----------------------------------------------------
Fax | 773-475-7454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3152 W. 47TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-321-9019
-----------------------------------------------------
Fax | 773-475-7454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MARINA ZHANG
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 312-447-4334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------