MEDICARE: YULISSA VANESSA CARDENAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1710718515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YULISSA VANESSA CARDENAS

Provider Business Mailing Address
First Line	:	484 LONGCOMMON RD
Second Line	:
City	:	RIVERSIDE
State	:	IL
Zip	:	60546-1745
Country	:	US
Telephone Number	:	708-205-9920
Fax Number	:

Provider Business Practice Location Address
First Line	:	7222 W CERMAK RD STE 703
Second Line	:
City	:	RIVERSIDE
State	:	IL
Zip	:	60546-1423
Country	:	US
Telephone Number	:	773-312-3612
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2024
Last Update Date	:	08/13/2024

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