Healthcare Provider Details

I. General information

NPI: 1093203150
Provider Name (Legal Business Name): RICARDO E ESPINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8644 S 86TH AVE APT 113
JUSTICE IL
60458-2113
US

IV. Provider business mailing address

3843 W 63RD ST
CHICAGO IL
60629-4623
US

V. Phone/Fax

Practice location:
  • Phone: 708-546-0806
  • Fax:
Mailing address:
  • Phone: 773-884-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: