Healthcare Provider Details

I. General information

NPI: 1104549880
Provider Name (Legal Business Name): YVONNE GONZALEZ LAC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 SKOKIE VALLEY RD
HIGHLAND PARK IL
60035-2361
US

IV. Provider business mailing address

4454 N ALBANY AVE
CHICAGO IL
60625-8289
US

V. Phone/Fax

Practice location:
  • Phone: 224-765-5550
  • Fax:
Mailing address:
  • Phone: 773-443-3708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198001524
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227007728
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: