Healthcare Provider Details

I. General information

NPI: 1124766266
Provider Name (Legal Business Name): MS. LORIE ESTHER FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 N CENTRAL AVE
CHICAGO IL
60639-1351
US

IV. Provider business mailing address

4222 W POTOMAC AVE
CHICAGO IL
60651-1854
US

V. Phone/Fax

Practice location:
  • Phone: 773-360-1389
  • Fax: 773-687-9412
Mailing address:
  • Phone: 773-818-9430
  • Fax: 773-687-9412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.108067
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number150.108067
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: