Healthcare Provider Details

I. General information

NPI: 1598248767
Provider Name (Legal Business Name): MRS. YOLANDA BUENROSTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 W 125TH AVE
CROWN POINT IN
46307-8751
US

IV. Provider business mailing address

5001 W 125TH AVE
CROWN POINT IN
46307-8751
US

V. Phone/Fax

Practice location:
  • Phone: 773-418-7609
  • Fax:
Mailing address:
  • Phone: 773-418-7609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: