Basic Information
| Provider Information | |||||||||
| NPI: | 1356070874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5254 SOLUTION CENTER UIC BEHAVIORAL HEALTH CLINIC | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606770001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129961000 | ||||||||
| FaxNumber: | 3129961001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1640 W ROOSEVELT RD | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606081316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124138043 | ||||||||
| FaxNumber: | 3124138333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2022 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | CUMMINGS | ||||||||
| AuthorizedOfficialFirstName: | ABRIANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | LEAD CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7737574364 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.