Healthcare Provider Details

I. General information

NPI: 1750029682
Provider Name (Legal Business Name): FLORA CARRANZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 11/29/2022
Certification Date: 11/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N COUNTY FARM RD
WHEATON IL
60187-3977
US

IV. Provider business mailing address

111 N COUNTY FARM RD
WHEATON IL
60187-3977
US

V. Phone/Fax

Practice location:
  • Phone: 630-510-5488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number22-203575
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: