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General NPI Number Information
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NPI Number | 1114219037
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Entity Type | Organization
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Legal Business Name | SUPPPORTED INDEPENDENCE
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Dates
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Enumeration Date | 05/11/2011
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Last Update Date | 05/11/2011
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Provider Practice Location Address
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Address Line | 30 S WACKER DR SUITE 2200
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City | CHICAGO
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State | IL
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Zip | 60606-7413
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Country | US
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Telephone | 630-667-7370
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Fax | 312-466-5601
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Provider Business Mailing Address
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Address Line | 30 S WACKER DR SUITE 2200
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City | CHICAGO
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State | IL
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Zip | 60606-7413
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Country | US
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Telephone | 630-667-7370
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Fax | 312-466-5601
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Authorized Official
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Title or Position | PRESIDENT
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Name | JESSICA LUCKETT
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Credential |
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Telephone | 630-667-7370
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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