Provider Demographics
NPI:1639311087
Name:UNITED MENTAL HEALTH ORGANIZATION OF ILLINOIS
Entity Type:Organization
Organization Name:UNITED MENTAL HEALTH ORGANIZATION OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:708-774-5645
Mailing Address - Street 1:3861 MARILYN DR
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1279
Mailing Address - Country:US
Mailing Address - Phone:708-774-5645
Mailing Address - Fax:708-679-9727
Practice Address - Street 1:17569 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2007
Practice Address - Country:US
Practice Address - Phone:708-922-3840
Practice Address - Fax:708-922-3850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6044301OtherHEALTH CARE & FAMILY SERVICES ID