Healthcare Provider Details

I. General information

NPI: 1356337612
Provider Name (Legal Business Name): MARK RAMIREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 BAY SCOTT CIR STE. 109
NAPERVILLE IL
60540-1129
US

IV. Provider business mailing address

1819 BAY SCOTT CIR STE 109
NAPERVILLE IL
60540-1130
US

V. Phone/Fax

Practice location:
  • Phone: 630-357-2456
  • Fax: 630-357-2482
Mailing address:
  • Phone: 630-357-2456
  • Fax: 630-357-2482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180000241
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166-000890
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: