Provider Demographics
NPI: | 1164475018 |
---|---|
Name: | BOBBY E. WRIGHT COMPREHENSIVE BEHAVIORAL HEALTH CENTER, INC. |
Entity Type: | Organization |
Organization Name: | BOBBY E. WRIGHT COMPREHENSIVE BEHAVIORAL HEALTH CENTER, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DIRECTOR OF COMPLIANCE |
Authorized Official - Prefix: | |
Authorized Official - First Name: | TAKASHA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MCINTOSH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 773-722-7900 |
Mailing Address - Street 1: | 5002 W MADISON ST |
Mailing Address - Street 2: | |
Mailing Address - City: | CHICAGO |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60644-4127 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 773-722-7900 |
Mailing Address - Fax: | 773-638-6774 |
Practice Address - Street 1: | 5002 W MADISON ST |
Practice Address - Street 2: | |
Practice Address - City: | CHICAGO |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60644-4127 |
Practice Address - Country: | US |
Practice Address - Phone: | 773-722-7900 |
Practice Address - Fax: | 773-638-6774 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-19 |
Last Update Date: | 2024-04-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 002520001 | 101YA0400X, 101YM0800X, 103TM1800X |
251S00000X, 261QM0801X, 261QM2800X, 261QR0405X, 276400000X, 324500000X, 3245S0500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 103TM1800X | Behavioral Health & Social Service Providers | Psychologist | Intellectual & Developmental Disabilities | Group - Multi-Specialty |
No | 251S00000X | Agencies | Community/Behavioral Health | ||
No | 261QM2800X | Ambulatory Health Care Facilities | Clinic/Center | Methadone | |
No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | |
No | 276400000X | Hospital Units | Rehabilitation, Substance Use Disorder Unit | ||
No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | ||
No | 3245S0500X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | ========= | Medicaid | |
IL | 695850 | Medicare ID - Type Unspecified |