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General NPI Number Information
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NPI Number | 1306653613
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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 | 12/11/2024
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Last Update Date | 01/17/2025
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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 | 708-450-3500
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Fax | 708-236-5184
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Provider Business Mailing 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 | 708-450-3500
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Fax | 708-236-5184
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | RITA JEAN MCCONVILLE
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Credential | CPA
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Telephone | 708-236-5164
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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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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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