Provider Demographics
NPI:1376680512
Name:CARITAS
Entity type:Organization
Organization Name:CARITAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSECA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-572-8228
Mailing Address - Street 1:1301 WEST 22ND STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523
Mailing Address - Country:US
Mailing Address - Phone:630-572-0556
Mailing Address - Fax:630-572-0566
Practice Address - Street 1:140 NORTH ASHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:312-850-9411
Practice Address - Fax:312-850-3288
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARITAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-30
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA-0554-0001-AOtherILLINOIS DEPARTMENT OF HUMAN SERVICES - SUPR
IL023Medicaid