Provider Demographics
NPI:1083634901
Name:COMMUNITY COUNSELING CENTERS OF CHICAGO
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING CENTERS OF CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOPERA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-769-0205
Mailing Address - Street 1:4740 N. CLARK ST.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640
Mailing Address - Country:US
Mailing Address - Phone:773-769-0205
Mailing Address - Fax:773-765-0801
Practice Address - Street 1:4740 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4689
Practice Address - Country:US
Practice Address - Phone:773-769-0205
Practice Address - Fax:773-765-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04029261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1616824OtherBLUE CROSS BLUE SHIELD
IL=========002Medicaid
322860Medicare PIN