Provider Demographics
NPI:1598835431
Name:FIRST LIFE BEHAVIORAL HEALTH INC.
Entity Type:Organization
Organization Name:FIRST LIFE BEHAVIORAL HEALTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:708-210-9085
Mailing Address - Street 1:465 W 162ND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2010
Mailing Address - Country:US
Mailing Address - Phone:708-210-9085
Mailing Address - Fax:708-210-9386
Practice Address - Street 1:465 W 162ND ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2010
Practice Address - Country:US
Practice Address - Phone:708-210-9085
Practice Address - Fax:708-210-9386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208497Medicare ID - Type UnspecifiedPART B