Provider Demographics
NPI:1578839700
Name:FAMILY ADOLESCENT CHILD TREATMENT SERVICE LLC
Entity Type:Organization
Organization Name:FAMILY ADOLESCENT CHILD TREATMENT SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:BOHO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-282-2322
Mailing Address - Street 1:4801 W PETERSON AVE
Mailing Address - Street 2:401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5713
Mailing Address - Country:US
Mailing Address - Phone:773-282-2322
Mailing Address - Fax:773-282-2853
Practice Address - Street 1:4801 W PETERSON AVE
Practice Address - Street 2:401
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5713
Practice Address - Country:US
Practice Address - Phone:773-282-2322
Practice Address - Fax:773-282-2853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004665103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty