Healthcare Provider Details

I. General information

NPI: 1568215622
Provider Name (Legal Business Name): EMELISSA MEJIA AGUILAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 N HALSTED ST STE 105
CHICAGO IL
60642-7886
US

IV. Provider business mailing address

2218 S LARAMIE AVE APT 4
CICERO IL
60804-2818
US

V. Phone/Fax

Practice location:
  • Phone: 312-298-9224
  • Fax:
Mailing address:
  • Phone: 979-253-1895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.020064
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: