Healthcare Provider Details

I. General information

NPI: 1720771009
Provider Name (Legal Business Name): AIN O ECCLES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N SHEFFIELD AVE
CHICAGO IL
60657-5081
US

IV. Provider business mailing address

9420 S CHARLES ST
CHICAGO IL
60643-5824
US

V. Phone/Fax

Practice location:
  • Phone: 262-358-6499
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: