Healthcare Provider Details

I. General information

NPI: 1699182642
Provider Name (Legal Business Name): IN HOME COUNSELING FOR SENIORS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2318 N LOWELL AVE
CHICAGO IL
60639-3520
US

IV. Provider business mailing address

2318 N LOWELL AVE
CHICAGO IL
60639-3520
US

V. Phone/Fax

Practice location:
  • Phone: 773-550-3143
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number149.015412
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number149.015412
License Number StateIL

VIII. Authorized Official

Name: ELSA MONTOTO VEGA
Title or Position: LCSW
Credential:
Phone: 773-550-3143