=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376030643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY FIRST DOMESTIC & FAMILY COUNSELING CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2018
-----------------------------------------------------
Last Update Date | 10/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9522 S HALSTED ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60628-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-595-5794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9522 S HALSTED ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60628-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-595-5794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TIFFANY BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-595-5794
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------