Healthcare Provider Details

I. General information

NPI: 1356136758
Provider Name (Legal Business Name): LIDYA AGUSTINA TANDAYU MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 WELD RD STE 9
ELGIN IL
60123-5896
US

IV. Provider business mailing address

6800 W RAVEN ST UNIT 410
CHICAGO IL
60631-2529
US

V. Phone/Fax

Practice location:
  • Phone: 847-707-2689
  • Fax:
Mailing address:
  • Phone: 773-695-9559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178019770
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: