Healthcare Provider Details

I. General information

NPI: 1396526273
Provider Name (Legal Business Name): LOURDES CARVAJAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1066 W GRANVILLE AVE UNIT 5
CHICAGO IL
60660-2156
US

IV. Provider business mailing address

6427 N MAGNOLIA AVE
CHICAGO IL
60626-5305
US

V. Phone/Fax

Practice location:
  • Phone: 773-335-3509
  • Fax: 312-489-8138
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.041058
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: