Provider Demographics
NPI:1558677526
Name:CCLV 23
Entity Type:Organization
Organization Name:CCLV 23
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:KANTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-549-1102
Mailing Address - Street 1:3223 N SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2298
Mailing Address - Country:US
Mailing Address - Phone:773-549-5886
Mailing Address - Fax:773-549-3265
Practice Address - Street 1:3223 N SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2298
Practice Address - Country:US
Practice Address - Phone:773-549-5886
Practice Address - Fax:773-549-3265
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNSELING CENTER OF LAKE VIEW
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-27
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04040261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========0004Medicaid