Healthcare Provider Details

I. General information

NPI: 1225121262
Provider Name (Legal Business Name): CLAY DEBRA CHALUPA LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4085 N BROADWAY ST
CHICAGO IL
60613-2117
US

IV. Provider business mailing address

4085 N BROADWAY ST
CHICAGO IL
60613-2117
US

V. Phone/Fax

Practice location:
  • Phone: 773-883-9100
  • Fax: 773-883-0005
Mailing address:
  • Phone: 773-883-9100
  • Fax: 773-883-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: