Healthcare Provider Details

I. General information

NPI: 1386724243
Provider Name (Legal Business Name): JUDITH MIZRACHI L.C.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5419 N SHERIDAN RD SUITE 103 A
CHICAGO IL
60640-1964
US

IV. Provider business mailing address

1347 W GREENLEAF AVE UNIT 2
CHICAGO IL
60626-2916
US

V. Phone/Fax

Practice location:
  • Phone: 773-575-4307
  • Fax: 773-764-2038
Mailing address:
  • Phone: 773-575-4307
  • Fax: 773-764-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-005474
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: