Provider Demographics
NPI:1457649246
Name:STICKNEY PUBLIC HEALTH DISTRICT
Entity Type:Organization
Organization Name:STICKNEY PUBLIC HEALTH DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUNOW
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-424-9200
Mailing Address - Street 1:6721 40TH ST
Mailing Address - Street 2:
Mailing Address - City:STICKNEY
Mailing Address - State:IL
Mailing Address - Zip Code:60402-4174
Mailing Address - Country:US
Mailing Address - Phone:708-788-9100
Mailing Address - Fax:708-788-4856
Practice Address - Street 1:6721 40TH ST
Practice Address - Street 2:
Practice Address - City:STICKNEY
Practice Address - State:IL
Practice Address - Zip Code:60402-4174
Practice Address - Country:US
Practice Address - Phone:708-788-9100
Practice Address - Fax:708-788-4856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6040201Medicaid
IL=========6040201Medicaid