MEDICARE: PILSEN-LITTLE VILLAGE COMMUNITY MENTAL HEALTH CENTER, INC.

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	251B00000X	Case Management Agency	A-0155-0001-A	IL
2	252Y00000X	Early Intervention Provider Agency	A-0155-0001-A	IL
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1073781811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PILSEN-LITTLE VILLAGE COMMUNITY MENTAL HEALTH CENTER, INC.

Provider Business Mailing Address
First Line	:	3113 W CERMAK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3449
Country	:	US
Telephone Number	:	773-277-3413
Fax Number	:	773-277-3517

Provider Business Practice Location Address
First Line	:	3113 W CERMAK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3449
Country	:	US
Telephone Number	:	773-277-3413
Fax Number	:	773-257-0912

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. FRANCISCO CISNEROS
Credential	:	MA, CADC
Telephone Number	:	773-579-0832

Provider Enumeration Date	:	02/14/2008
Last Update Date	:	02/14/2022

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