=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588486195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HISPANIC THERAPEUTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2024
-----------------------------------------------------
Last Update Date | 05/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5719 W FULLERTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60639-2341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-865-2384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5719 W FULLERTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60639-2341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-865-2384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NORMA MARTINEZ
-----------------------------------------------------
Credential | LSW
-----------------------------------------------------
Telephone | 773-865-2384
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------