Provider Demographics
NPI:1619182557
Name:CCL THERAPEUTIC SERVICES, INC.
Entity Type:Organization
Organization Name:CCL THERAPEUTIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK LAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:630-688-0289
Mailing Address - Street 1:9620 US ROUTE 34
Mailing Address - Street 2:SUITE E
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-1394
Mailing Address - Country:US
Mailing Address - Phone:630-688-0289
Mailing Address - Fax:
Practice Address - Street 1:9620 US ROUTE 34
Practice Address - Street 2:SUITE E
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1394
Practice Address - Country:US
Practice Address - Phone:630-688-0289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490109851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149010985OtherSTATE CLINICAL LICENSE