Healthcare Provider Details

I. General information

NPI: 1205571171
Provider Name (Legal Business Name): JOSE ZAVALA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 LAKE ST
OAK PARK IL
60302-2606
US

IV. Provider business mailing address

14 LAKE ST
OAK PARK IL
60302-2606
US

V. Phone/Fax

Practice location:
  • Phone: 773-584-4178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number149025090
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149025090
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: