Provider Demographics
NPI:1891200317
Name:ADVANCED CLINICAL HEALTH SERVICE CORPORATION
Entity Type:Organization
Organization Name:ADVANCED CLINICAL HEALTH SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:EDRENA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-879-2274
Mailing Address - Street 1:2925 S WABASH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3583
Mailing Address - Country:US
Mailing Address - Phone:773-879-2274
Mailing Address - Fax:312-225-6742
Practice Address - Street 1:2925 S WABASH AVE STE 102
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3583
Practice Address - Country:US
Practice Address - Phone:773-879-2274
Practice Address - Fax:312-225-6742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490182581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty