MEDICARE: BEVERLY BEHAVIORAL HEALTH, LTD

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	060-009832	IL

General Provider Information

NPI Number	:	1588839260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEVERLY BEHAVIORAL HEALTH, LTD

Provider Business Mailing Address
First Line	:	9933 S WESTERN AVE
Second Line	:	SUITE 104
City	:	CHICAGO
State	:	IL
Zip	:	60643-1810
Country	:	US
Telephone Number	:	773-779-9700
Fax Number	:	773-779-9732

Provider Business Practice Location Address
First Line	:	9933 S WESTERN AVE
Second Line	:	SUITE 104
City	:	CHICAGO
State	:	IL
Zip	:	60643-1810
Country	:	US
Telephone Number	:	773-779-9700
Fax Number	:	773-779-9732

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TRACI E POWELL
Credential	:	MD
Telephone Number	:	773-779-9700

Provider Enumeration Date	:	04/24/2008
Last Update Date	:	04/30/2009

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