Healthcare Provider Details

I. General information

NPI: 1134040777
Provider Name (Legal Business Name): WANDA E DELEON-ROSARIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 N CLARK ST STE 405
CHICAGO IL
60614-7730
US

IV. Provider business mailing address

2551 N CLARK ST STE 405
CHICAGO IL
60614-7730
US

V. Phone/Fax

Practice location:
  • Phone: 773-984-4762
  • Fax:
Mailing address:
  • Phone: 773-984-4762
  • Fax: 773-512-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178021981
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: