Provider Demographics
NPI:1376080572
Name:MC DERMOTT CENTER
Entity Type:Organization
Organization Name:MC DERMOTT CENTER
Other - Org Name:HAYMARKET CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSTIG
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:312-226-7984
Mailing Address - Street 1:932 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2217
Mailing Address - Country:US
Mailing Address - Phone:312-226-7984
Mailing Address - Fax:312-226-8048
Practice Address - Street 1:108 N SANGAMON ST FL 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2202
Practice Address - Country:US
Practice Address - Phone:312-226-7984
Practice Address - Fax:312-226-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 324500000X
IL17001320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0349-0056Medicaid