Provider Demographics
NPI:1093423790
Name:CHICAGO MENTAL AND LIFE WELLNESS INSTITUTE
Entity Type:Organization
Organization Name:CHICAGO MENTAL AND LIFE WELLNESS INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-569-0791
Mailing Address - Street 1:3817 W 85TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-3709
Mailing Address - Country:US
Mailing Address - Phone:773-569-0791
Mailing Address - Fax:
Practice Address - Street 1:8547 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2249
Practice Address - Country:US
Practice Address - Phone:773-569-0791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-10
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health