Healthcare Provider Details

I. General information

NPI: 1750005682
Provider Name (Legal Business Name): RODRIGO EFRAIN ESPINOZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 W WELLINGTON AVE
CHICAGO IL
60657-6709
US

IV. Provider business mailing address

913 W WELLINGTON AVE
CHICAGO IL
60657-6709
US

V. Phone/Fax

Practice location:
  • Phone: 312-834-3717
  • Fax: 872-843-9008
Mailing address:
  • Phone: 312-834-3717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: