=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912584327
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURTON HOMES COMMUNITY OUTREACH NFP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2021
-----------------------------------------------------
Last Update Date | 07/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9204 S COMMERCIAL AVE STE 308
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-2197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-404-7184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10208 S INDIANAPOLIS AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-6033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-216-4995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ CEO
-----------------------------------------------------
Name | BRIANA SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-404-7184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------