Healthcare Provider Details

I. General information

NPI: 1134675093
Provider Name (Legal Business Name): DORALIS CORIANO ORTIZ LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W BELMONT AVE STE 300
CHICAGO IL
60657-3200
US

IV. Provider business mailing address

661 W LAKE ST STE 2S
CHICAGO IL
60661-1034
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-1310
  • Fax:
Mailing address:
  • Phone: 773-389-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.013997
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: