Healthcare Provider Details

I. General information

NPI: 1932701935
Provider Name (Legal Business Name): EDGAR MERAZ MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6415 STANLEY AVE
BERWYN IL
60402-3130
US

IV. Provider business mailing address

3330 W 60TH ST
CHICAGO IL
60629-3629
US

V. Phone/Fax

Practice location:
  • Phone: 708-308-6830
  • Fax:
Mailing address:
  • Phone: 773-558-7619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: