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General NPI Number Information
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NPI Number | 1134553076
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Entity Type | Organization
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Legal Business Name | PROVISO-LEYDEN COUNCIL FOR COMMUNITY ACTION INC
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Dates
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Enumeration Date | 08/28/2013
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Last Update Date | 03/20/2024
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Provider Practice Location Address
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Address Line | 411 MADISON ST
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City | MAYWOOD
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State | IL
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Zip | 60153-2136
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Country | US
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Telephone | 708-236-5042
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Fax |
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Provider Business Mailing Address
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Address Line | 411 WEST MADISON STREET
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City | MAYWOOD
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State | IL
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Zip | 60153
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Country | US
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Telephone | 708-236-5042
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CLAUDE PORTER
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Credential |
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Telephone | 708-450-3500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 276400000X
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Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM2800X
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Taxonomy Name | Methadone Clinic
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License Number |
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License Number State |
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