=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679628705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTUMN HEALTHCARE OF ILLINOIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4505 S DREXEL BLVD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60653-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-285-0550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9449 S KEDZIE AVE STE142
-----------------------------------------------------
City | EVERGREEN PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60805-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-420-3481
-----------------------------------------------------
Fax | 773-420-3597
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. PAMELA ANN BRAZELTON-SYKES
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 773-420-3481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------