=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356706881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CTF ILLINOIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2015
-----------------------------------------------------
Last Update Date | 02/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 E 162ND ST
-----------------------------------------------------
City | SOUTH HOLLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60473-2326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-429-1260
-----------------------------------------------------
Fax | 708-429-9701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18230 ORLAND PKWY
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60467-5688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-429-1260
-----------------------------------------------------
Fax | 708-429-9107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE ASSISTANT
-----------------------------------------------------
Name | KELLI L CODY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-429-1260
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 4128
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 4128
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------