Healthcare Provider Details

I. General information

NPI: 1972111334
Provider Name (Legal Business Name): CARMEN TATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2803 LARKSPUR LN
HAZEL CREST IL
60429-2145
US

IV. Provider business mailing address

2803 LARKSPUR LN
HAZEL CREST IL
60429-2145
US

V. Phone/Fax

Practice location:
  • Phone: 708-608-3241
  • Fax:
Mailing address:
  • Phone: 708-305-1193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009380
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150102674
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number110546
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number42113793
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: