Healthcare Provider Details

I. General information

NPI: 1548063373
Provider Name (Legal Business Name): TANIA TREJO LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 S ARCHER AVE
CHICAGO IL
60638-1659
US

IV. Provider business mailing address

4915 W WINNEMAC AVE
CHICAGO IL
60630-2434
US

V. Phone/Fax

Practice location:
  • Phone: 773-709-9298
  • Fax:
Mailing address:
  • Phone: 773-709-9298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number150.110721
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: