=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508824244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER ON HALSTED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 10/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3656 N HALSTED ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-472-6469
-----------------------------------------------------
Fax | 773-472-6643
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3656 N HALSTED ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-472-6469
-----------------------------------------------------
Fax | 773-472-6643
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MODESTO VALLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-472-6469
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------