Healthcare Provider Details

I. General information

NPI: 1487148730
Provider Name (Legal Business Name): EDDY BARAJAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5341 W CERMAK RD
CICERO IL
60804-2892
US

IV. Provider business mailing address

4655 S LAKE PARK AVE APT 227
CHICAGO IL
60653-4534
US

V. Phone/Fax

Practice location:
  • Phone: 708-656-6430
  • Fax:
Mailing address:
  • Phone: 312-375-6990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: