Healthcare Provider Details

I. General information

NPI: 1255773099
Provider Name (Legal Business Name): BETZABE ADAME
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 S WESTERN AVE
CHICAGO IL
60608
US

IV. Provider business mailing address

966 W 21ST ST
CHICAGO IL
60608-4511
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax:
Mailing address:
  • Phone: 773-254-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.011250
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180012521
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: