Healthcare Provider Details

I. General information

NPI: 1609346410
Provider Name (Legal Business Name): CHANTAL PICO MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

IV. Provider business mailing address

2151 EMILY DR
BOLINGBROOK IL
60490-4927
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-0205
  • Fax: 773-765-0801
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180011900
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: