Provider Demographics
NPI:1881919488
Name:CHILDHOOD TRAUMA TREATMENT PROGRAM OF ADVOCATE HEALTH & HOSPITALS CORP
Entity type:Organization
Organization Name:CHILDHOOD TRAUMA TREATMENT PROGRAM OF ADVOCATE HEALTH & HOSPITALS CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CARROCCIA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:800-216-1110
Mailing Address - Street 1:PO BOX 776
Mailing Address - Street 2:CHILDHOOD TRAUMA TREATMENT PROGRAM
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60454-0776
Mailing Address - Country:US
Mailing Address - Phone:800-216-1110
Mailing Address - Fax:708-346-4868
Practice Address - Street 1:4700 W 95TH ST
Practice Address - Street 2:LL5
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2533
Practice Address - Country:US
Practice Address - Phone:800-216-1110
Practice Address - Fax:708-346-4868
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY CARE NETWORK OF ADVOCATE HEALTH & HOSPITALS CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health