MEDICARE: C2ACT, 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	149011093	IL
2	103K00000X	Behavior Analyst
3	1041C0700X	Clinical Social Worker
4	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1790054542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C2ACT, LLC

Provider Business Mailing Address
First Line	:	3417 N KENNICOTT AVE STE A
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-7824
Country	:	US
Telephone Number	:	224-210-6694
Fax Number	:	224-836-5174

Provider Business Practice Location Address
First Line	:	3417 N KENNICOTT AVE STE A
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-7824
Country	:	US
Telephone Number	:	224-210-6694
Fax Number	:	224-836-5174

Authorized Official
Title or Position	:	LICENSED CLINICAL SOCIAL WORKER
Name	:	MARJORIE DIAZ RODRIGUEZ
Credential	:	MA
Telephone Number	:	224-210-6694

Provider Enumeration Date	:	12/23/2011
Last Update Date	:	03/01/2022

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