Healthcare Provider Details

I. General information

NPI: 1073104741
Provider Name (Legal Business Name): MARTIN CUEVAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 TURNBERRY CT
LAKE IN THE HILLS IL
60156-6765
US

IV. Provider business mailing address

6 TURNBERRY CT
LAKE IN THE HILLS IL
60156-6765
US

V. Phone/Fax

Practice location:
  • Phone: 718-915-7878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-20771
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149022902
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: