Provider Demographics
NPI:1699009092
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:MONSIGNOR 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 LA SALLE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6202 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2029
Practice Address - Country:US
Practice Address - Phone:312-655-7984
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:2009-10-01
Last Update Date:2023-10-17
Deactivation Date:2023-05-12
Deactivation Code:
Reactivation Date:2023-10-17
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
IL0039714330OtherDCFS-MEDICAID