Healthcare Provider Details

I. General information

NPI: 1164780664
Provider Name (Legal Business Name): CRISTINA NOEL BETANCES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRISTINA NOEL VAZQUEZ

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 LINCOLN HWY #321
MATTESON IL
60443-2316
US

IV. Provider business mailing address

6120 W SCHOOL ST
CHICAGO IL
60634-4109
US

V. Phone/Fax

Practice location:
  • Phone: 773-420-3481
  • Fax: 773-420-3597
Mailing address:
  • Phone: 773-255-5481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.007700
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: