MEDICARE: CENTER ON HALSTED

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01634461	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1508824244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER ON HALSTED

Provider Business Mailing Address
First Line	:	3656 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-4316
Country	:	US
Telephone Number	:	773-472-6469
Fax Number	:	773-472-6643

Provider Business Practice Location Address
First Line	:	3656 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-4316
Country	:	US
Telephone Number	:	773-472-6469
Fax Number	:	773-472-6643

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MODESTO VALLE
Credential	:
Telephone Number	:	773-472-6469

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	10/21/2015

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Directions to “CENTER ON HALSTED ” Practice Location

Language	Start Address	Practice Location

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