Provider Demographics
NPI:1679951834
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: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 1:721 N LA SALLE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3751
Practice Address - Country:US
Practice Address - Phone:773-349-8052
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:2015-05-08
Last Update Date:2023-05-31
Deactivation Date:2023-05-12
Deactivation Code:
Reactivation Date:2023-05-31
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04019Medicaid