1295154813 NPI number — CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO

Table of content: (NPI 1295154813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295154813 NPI number — CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKE COUNTY BEHAVIORAL HEALTH SERVICES
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295154813
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/12/2023
NPI Reactivation Date:
12/28/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
671 S LEWIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUKEGAN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60085-6101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-782-4154
Provider Business Mailing Address Fax Number:
847-782-1030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
671 S LEWIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKEGAN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60085-6101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-782-4154
Provider Business Practice Location Address Fax Number:
847-782-1030
Provider Enumeration Date:
04/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BOLAND
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR, PRESIDENT AND CEO
Authorized Official Telephone Number:
312-655-7320

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , with the licence number: 04019 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04019 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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