Healthcare Provider Details

I. General information

NPI: 1548043417
Provider Name (Legal Business Name): ELIDETH VAZQUEZ MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 W JEFFERSON ST
JOLIET IL
60435-5261
US

IV. Provider business mailing address

8609 W BRYN MAWR AVE STE 204
CHICAGO IL
60631-3524
US

V. Phone/Fax

Practice location:
  • Phone: 224-487-8578
  • Fax:
Mailing address:
  • Phone: 773-644-7787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: