Healthcare Provider Details

I. General information

NPI: 1649417825
Provider Name (Legal Business Name): DELIA DE AVILA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 01/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 N SHEFFIELD AVE
CHICAGO IL
60657-2210
US

IV. Provider business mailing address

3142 S PULASKI RD
CHICAGO IL
60623-4917
US

V. Phone/Fax

Practice location:
  • Phone: 773-549-5886
  • Fax: 773-549-5892
Mailing address:
  • Phone: 773-732-1461
  • Fax: 773-549-5892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-01334
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: