=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609045624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH DISABILITY AGING RESOURCE ADVOCATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2008
-----------------------------------------------------
Last Update Date | 09/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 E OGDEN AVE # 344
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-332-9559
-----------------------------------------------------
Fax | 708-332-9559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 E OGDEN AVE # 344
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-332-9559
-----------------------------------------------------
Fax | 708-332-9559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | E NIELSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-332-9559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1609045624
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------