Organization
BREAKING FREE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. KIM CACCIATO (BILLING SPECIALIST)
(630) 572-8228
Entity
Organization
Contact information
Practice address
800 W 5TH AVE, SUITE 102 B, NAPERVILLE, IL 60563-8965
(630) 355-2585
(630) 355-2676
Mailing address
800 W 5TH AVE, SUITE 102 B, NAPERVILLE, IL 60563-8965
(630) 355-2585
(630) 355-2676
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
A-0380-0004-A
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0380
DASA PROVIDER NUMBER
IL
01
—
1839
BLUE CROSS PROVIDER NUMBE
IL
Enumeration date
01/30/2007
Last updated
08/22/2020
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