Provider Demographics
NPI:1023848363
Name:BONFIRE CLINICAL SERVICES
Entity type:Organization
Organization Name:BONFIRE CLINICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:LINDSAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:312-404-7864
Mailing Address - Street 1:4442 N SAWYER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-4885
Mailing Address - Country:US
Mailing Address - Phone:312-404-7864
Mailing Address - Fax:
Practice Address - Street 1:4442 N SAWYER AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-4885
Practice Address - Country:US
Practice Address - Phone:312-404-7864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1114087897Medicaid