Healthcare Provider Details

I. General information

NPI: 1740889070
Provider Name (Legal Business Name): DEBORAH JOY NAZARETH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 E ALGONQUIN RD
ALGONQUIN IL
60102-3084
US

IV. Provider business mailing address

620 W HIGHLAND AVE APT 302
ELGIN IL
60123-5361
US

V. Phone/Fax

Practice location:
  • Phone: 224-357-0540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number178.016374
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: