Provider Demographics
NPI:1245646272
Name:CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Entity type:Organization
Organization Name:CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:F
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-655-7167
Mailing Address - Street 1:1800 N HERMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1161
Mailing Address - Country:US
Mailing Address - Phone:312-655-7167
Mailing Address - Fax:
Practice Address - Street 1:1717 RAND RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-3509
Practice Address - Country:US
Practice Address - Phone:847-376-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-10
Last Update Date:2023-05-31
Deactivation Date:2023-05-12
Deactivation Code:
Reactivation Date:2023-05-31
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 104100000X, 1041C0700X, 171M00000X, 251B00000X
IL04019261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04019Medicaid