Provider Demographics
NPI:1548608482
Name:COMMUNITY COUNSELING CENTERS OF CHICAGO
Entity Type:Organization
Organization Name:COMMUNITY COUNSELING CENTERS OF CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DURKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-765-0810
Mailing Address - Street 1:4740 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4689
Mailing Address - Country:US
Mailing Address - Phone:773-769-0205
Mailing Address - Fax:773-765-0794
Practice Address - Street 1:1123 EMERSON ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3100
Practice Address - Country:US
Practice Address - Phone:224-356-0356
Practice Address - Fax:224-356-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04029251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL322860Medicare PIN