Basic Information
| Provider Information | |||||||||
| NPI: | 1083664510 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHICAGO CHRISTIAN COUNSELING CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15127 S 73RD AVE | ||||||||
| Address2: | G | ||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604624398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003616880 | ||||||||
| FaxNumber: | 7088455505 | ||||||||
| Practice Location | |||||||||
| Address1: | 15127 S 73RD AVE | ||||||||
| Address2: | G | ||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604624398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088455500 | ||||||||
| FaxNumber: | 7088455505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 09/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | KUBA | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7088455500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.