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General NPI Number Information
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NPI Number | 1891200317
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Entity Type | Organization
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Legal Business Name | ADVANCED CLINICAL HEALTH SERVICE CORPORATION
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Dates
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Enumeration Date | 12/06/2017
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Last Update Date | 12/06/2017
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Provider Practice Location Address
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Address Line | 2925 S WABASH AVE STE 102
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City | CHICAGO
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State | IL
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Zip | 60616-3583
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Country | US
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Telephone | 773-879-2274
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Fax | 312-225-6742
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Provider Business Mailing Address
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Address Line | 2925 S WABASH AVE STE 102
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City | CHICAGO
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State | IL
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Zip | 60616-3583
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Country | US
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Telephone | 773-879-2274
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Fax | 312-225-6742
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | EDRENA JOY DAVIS
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Credential | LCSW
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Telephone | 773-879-2274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149018258
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License Number State | IL
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