Provider Demographics
NPI:1295154813
Name:CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Entity type:Organization
Organization Name:CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR, PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:312-655-7320
Mailing Address - Street 1:671 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-6101
Mailing Address - Country:US
Mailing Address - Phone:847-782-4154
Mailing Address - Fax:847-782-1030
Practice Address - Street 1:671 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-6101
Practice Address - Country:US
Practice Address - Phone:847-782-4154
Practice Address - Fax:847-782-1030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC CHARITIES OF THE ARCHDIOCESE OF CHICAGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-10
Last Update Date:2023-12-28
Deactivation Date:2023-05-12
Deactivation Code:
Reactivation Date:2023-12-28
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 343900000X, 101YP2500X, 251B00000X, 251E00000X
IL04019261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04019Medicaid