Provider Demographics
NPI:1225621295
Name:A BEAUTIFUL MIND CHICAGO
Entity Type:Organization
Organization Name:A BEAUTIFUL MIND CHICAGO
Other - Org Name:A BEAUTIFUL MIND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHIQUITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-340-8826
Mailing Address - Street 1:5113 S HARPER AVE # 2C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4119
Mailing Address - Country:US
Mailing Address - Phone:773-304-3699
Mailing Address - Fax:
Practice Address - Street 1:5113 S HARPER AVE # 2C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4119
Practice Address - Country:US
Practice Address - Phone:773-304-3699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0Medicaid