Organization
LAKESIDE COMMUNITY COMMITTEE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TIFFANY JOHNSON EDD (CHIEF OPERATING OFFICER)
(773) 841-4368
Entity
Organization
Contact information
Practice address
7418 S COTTAGE GROVE AVE, CHICAGO, IL 60619-1912
(773) 224-9217
(773) 224-9468
Mailing address
7418 S COTTAGE GROVE AVE, CHICAGO, IL 60619-1912
(773) 224-9217
(773) 224-9468
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
—
—
Other
Enumeration date
05/30/2024
Last updated
05/30/2024
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