Provider Demographics
NPI:1962663120
Name:HEARTLAND ALLIANCE HEALTH
Entity Type:Organization
Organization Name:HEARTLAND ALLIANCE HEALTH
Other - Org Name:HEARTLAND HEALTH OUTREACH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:STELLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-751-4129
Mailing Address - Street 1:4750 N SHERIDAN RD STE 449
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5078
Mailing Address - Country:US
Mailing Address - Phone:773-751-4129
Mailing Address - Fax:773-751-4175
Practice Address - Street 1:1207 W LELAND
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-6043
Practice Address - Country:US
Practice Address - Phone:773-334-7117
Practice Address - Fax:773-334-7277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019103TA0400X, 251S00000X
251B00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019Medicaid