Healthcare Provider Details

I. General information

NPI: 1174442149
Provider Name (Legal Business Name): AMNESTY VIVEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 SYDNEY AVE
LOVES PARK IL
61111-5921
US

IV. Provider business mailing address

515 SYDNEY AVE
LOVES PARK IL
61111-5921
US

V. Phone/Fax

Practice location:
  • Phone: 815-703-4628
  • Fax:
Mailing address:
  • Phone: 815-703-4628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: