Healthcare Provider Details

I. General information

NPI: 1801345079
Provider Name (Legal Business Name): LETICIA GOMEZ DELACASA M.A. LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 HEALTH SERVICES DR
DEKALB IL
60115-9637
US

IV. Provider business mailing address

832 AMHERST DR
SYCAMORE IL
60178-8917
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8616
  • Fax: 815-758-7569
Mailing address:
  • Phone: 312-925-2263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178009916
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: