MEDICARE: BLUE ISLAND COUNSELING 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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740828284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE ISLAND COUNSELING LLC

Provider Business Mailing Address
First Line	:	2343 CANAL ST
Second Line	:
City	:	BLUE ISLAND
State	:	IL
Zip	:	60406-2956
Country	:	US
Telephone Number	:	708-674-8735
Fax Number	:

Provider Business Practice Location Address
First Line	:	2343 CANAL ST
Second Line	:
City	:	BLUE ISLAND
State	:	IL
Zip	:	60406-2956
Country	:	US
Telephone Number	:	708-674-8735
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JUSTIN CHRISTOPHER KOZAK
Credential	:	LCPC
Telephone Number	:	708-829-5673

Provider Enumeration Date	:	12/16/2019
Last Update Date	:	12/16/2019

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Directions to “BLUE ISLAND COUNSELING LLC ” Practice Location

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