Provider Demographics
NPI:1588042931
Name:CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR, PRESIDENT, AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-655-7460
Mailing Address - Street 1:721 N. LASALLE ST.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654
Mailing Address - Country:US
Mailing Address - Phone:708-655-7000
Mailing Address - Fax:
Practice Address - Street 1:2310 W ROOSEVELT RD
Practice Address - Street 2:SUITE 2W
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1131
Practice Address - Country:US
Practice Address - Phone:312-655-7191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-18
Last Update Date:2023-12-28
Deactivation Date:2023-05-12
Deactivation Code:
Reactivation Date:2023-12-28
Provider Licenses
StateLicense IDTaxonomies
IL04019251S00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04019Medicaid