Healthcare Provider Details

I. General information

NPI: 1003452541
Provider Name (Legal Business Name): BLANCA E SEPULVEDA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E WASHINGTON ST STE 301
CHICAGO IL
60602-2142
US

IV. Provider business mailing address

2226 W 18TH PL APT 1B
CHICAGO IL
60608-2531
US

V. Phone/Fax

Practice location:
  • Phone: 312-252-9500
  • Fax:
Mailing address:
  • Phone: 773-895-3128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.021351
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: