Provider Demographics
NPI:1710049820
Name:THE SOUTH SUBURBAN COUNCIL ON ALCOHOLISM AND SUBSTANCE ABUSE
Entity Type:Organization
Organization Name:THE SOUTH SUBURBAN COUNCIL ON ALCOHOLISM AND SUBSTANCE ABUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-647-3305
Mailing Address - Street 1:1909 174TH ST
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429
Mailing Address - Country:US
Mailing Address - Phone:708-647-3333
Mailing Address - Fax:
Practice Address - Street 1:1909 174TH ST
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429
Practice Address - Country:US
Practice Address - Phone:708-647-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0621-0003-A261QR0401X, 261QR0405X
261QR0405X
ILA-0621-0004A324500000X
ILA-0621-0002-A324500000X
ILA-0621-0001-A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility