Provider Demographics
NPI:1851741888
Name:ASSOCIATION HOUSE OF CHICAGO
Entity Type:Organization
Organization Name:ASSOCIATION HOUSE OF CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:HARRIET
Authorized Official - Middle Name:
Authorized Official - Last Name:SADAUSKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-772-8009
Mailing Address - Street 1:1116 N KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-4152
Mailing Address - Country:US
Mailing Address - Phone:773-772-8009
Mailing Address - Fax:773-292-5490
Practice Address - Street 1:2849 W WALTON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4448
Practice Address - Country:US
Practice Address - Phone:773-435-3205
Practice Address - Fax:773-395-7340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 302R00000X
IL251C00000X, 251S00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5335OtherMEDICARE PTAN
IL102Medicaid