Provider Demographics
NPI:1497401855
Name:CHICAGO MIDWAY YOUTH CENTER
Entity Type:Organization
Organization Name:CHICAGO MIDWAY YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSQUEDA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-742-5728
Mailing Address - Street 1:725 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6728
Mailing Address - Country:US
Mailing Address - Phone:773-742-5728
Mailing Address - Fax:
Practice Address - Street 1:4051 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4638
Practice Address - Country:US
Practice Address - Phone:773-742-5728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty