MEDICARE: HENDRICKSON HOUSE OF SOBRIETY LLC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1124988480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HENDRICKSON HOUSE OF SOBRIETY LLC

Provider Business Mailing Address
First Line	:	4949 N NORMANDY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60656-4001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 S 49TH AVE
Second Line	:
City	:	CICERO
State	:	IL
Zip	:	60804-3634
Country	:	US
Telephone Number	:	464-927-9879
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEVE HENDRICKSON
Credential	:
Telephone Number	:	612-685-4958

Provider Enumeration Date	:	11/17/2025
Last Update Date	:	06/04/2026

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