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General NPI Number Information
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NPI Number | 1205179082
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Entity Type | Organization
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Legal Business Name | KEY TO HOPE
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Dates
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Enumeration Date | 03/31/2013
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Last Update Date | 03/31/2013
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Provider Practice Location Address
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Address Line | 1593 GREEN BAY RD
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City | HIGHLAND PARK
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State | IL
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Zip | 60035-3601
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Country | US
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Telephone | 312-218-2671
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Fax |
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Provider Business Mailing Address
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Address Line | 1593 GREEN BAY RD
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City | HIGHLAND PARK
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State | IL
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Zip | 60035-3601
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Country | US
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Telephone | 312-218-2671
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Fax |
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Authorized Official
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Title or Position | ABA LINE THERAPIST
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Name | MICHAEL JORDAIN JACKSON
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Credential |
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Telephone | 312-218-2671
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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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