Healthcare Provider Details

I. General information

NPI: 1609029404
Provider Name (Legal Business Name): MAURICIO J CIFUENTES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 10/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3047 N LINCOLN AVE UNIT 400
CHICAGO IL
60657-4274
US

IV. Provider business mailing address

6007 N SHERIDAN RD APT 36D
CHICAGO IL
60660-3012
US

V. Phone/Fax

Practice location:
  • Phone: 773-849-4709
  • Fax: 773-883-1535
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149011442
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: