MEDICARE: CHICAGO MENTAL AND LIFEWELLNESS INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1013507433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO MENTAL AND LIFEWELLNESS INSTITUTE

Provider Business Mailing Address
First Line	:	4645 S KING DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4148
Country	:	US
Telephone Number	:	773-439-9748
Fax Number	:

Provider Business Practice Location Address
First Line	:	4645 S KING DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4148
Country	:	US
Telephone Number	:	773-439-9748
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JIMALITA TILLMAN
Credential	:
Telephone Number	:	773-439-9748

Provider Enumeration Date	:	01/20/2021
Last Update Date	:	03/31/2021

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