Healthcare Provider Details

I. General information

NPI: 1720774359
Provider Name (Legal Business Name): MARIA CAMILA TOBON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 09/29/2024
Certification Date: 09/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 WASHINGTON ST STE 200
WAUKEGAN IL
60085-5564
US

IV. Provider business mailing address

415 WASHINGTON ST STE 200
WAUKEGAN IL
60085-5564
US

V. Phone/Fax

Practice location:
  • Phone: 224-392-1245
  • Fax:
Mailing address:
  • Phone: 224-255-6050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: