Provider Demographics
NPI:1932414000
Name:COUNSELING CENTER OF LAKE VIEW - SUBSTANCE ABUSE
Entity type:Organization
Organization Name:COUNSELING CENTER OF LAKE VIEW - SUBSTANCE ABUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CURTISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-549-1102
Mailing Address - Street 1:3225 N SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2210
Mailing Address - Country:US
Mailing Address - Phone:773-549-5886
Mailing Address - Fax:773-549-3265
Practice Address - Street 1:3225 N SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2210
Practice Address - Country:US
Practice Address - Phone:773-549-5886
Practice Address - Fax:773-549-3265
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNSELING CENTER OF LAKE VIEW
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA0127-0001-A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362743345001Medicaid