Healthcare Provider Details

I. General information

NPI: 1427439645
Provider Name (Legal Business Name): RALPH YANIZ MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 W 177TH ST 1F
HAZEL CREST IL
60429-2184
US

IV. Provider business mailing address

500 RAVINIA PL
ORLAND PARK IL
60462-3758
US

V. Phone/Fax

Practice location:
  • Phone: 708-745-3040
  • Fax: 708-799-1889
Mailing address:
  • Phone: 708-460-9833
  • Fax: 708-460-1117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180000406
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: