Healthcare Provider Details

I. General information

NPI: 1235063306
Provider Name (Legal Business Name): TATIANA NIEVES LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MAIN ST STE 200
PARK RIDGE IL
60068-4044
US

IV. Provider business mailing address

120 MAIN ST STE 200
PARK RIDGE IL
60068-4044
US

V. Phone/Fax

Practice location:
  • Phone: 847-720-4773
  • Fax:
Mailing address:
  • Phone: 773-512-0754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.117510
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: