Provider First Line Business Practice Location Address:
820 S DAMEN AVE
Provider Second Line Business Practice Location Address:
MENTAL HEALTH SERVICE LINE (116B)
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-3728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-569-6543
Provider Business Practice Location Address Fax Number:
312-569-6296
Provider Enumeration Date:
08/31/2006