Healthcare Provider Details

I. General information

NPI: 1083102545
Provider Name (Legal Business Name): ALEJANDRA Q CORONA LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 E PARK ST
CARBONDALE IL
62901-3812
US

IV. Provider business mailing address

3204 EAGLE WAY
CHICAGO IL
60678-1032
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-1151
  • Fax: 618-549-9540
Mailing address:
  • Phone: 630-717-2258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.102530
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: