Organization
NICASA
Active
Organization
NICASA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BRUCE JOHNSON (COO)
(847) 546-6450
Entity
Organization
Contact information
Practice address
31979 N FISH LKAE RD, ROUND LAKE, IL 60073
(847) 546-6450
(847) 546-6760
Mailing address
31979 N FISH LKAE RD, ROUND LAKE, IL 60073
(847) 546-6450
(847) 546-6760
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
CA06140005A
IL
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
A06140001A
STATE OF ILLINOIS
IL
01
—
A06140002A
STATE OF ILLINOIS
IL
01
—
A06140003A
STATE OF ILLINOIS
IL
01
—
A06140004A
STATE OF ILLINOIS
IL
01
—
A06140005A
STATE OF ILLINOIS
IL
05
—
CA06140001A
—
IL
05
—
CA06140002A
—
IL
05
—
CA06140005A
—
IL
Enumeration date
05/03/2007
Last updated
04/06/2021
Update your record
If you believe information in your NPPES record is inaccurate, or if you wish to update or deactivate your NPI, you can do so directly with CMS at https://nppes.cms.hhs.gov.
About Stedi
Stedi is the only programmable healthcare clearinghouse. You can use Stedi's APIs to process eligibility checks, claims, remits, and more.
Sign up