Healthcare Provider Details

I. General information

NPI: 1730702408
Provider Name (Legal Business Name): DANIELA FARIDI BUENO LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 W LAWRENCE AVE
CHICAGO IL
60625-5746
US

IV. Provider business mailing address

1400 W GREENLEAF AVE
CHICAGO IL
60626-2805
US

V. Phone/Fax

Practice location:
  • Phone: 773-508-6100
  • Fax:
Mailing address:
  • Phone: 773-508-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009354
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: