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General NPI Number Information
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NPI Number | 1780366179
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Entity Type | Individual
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Provider Name | KETTY BURGOS
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Gender | Female
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Dates
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Enumeration Date | 08/04/2023
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Last Update Date | 08/15/2023
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Provider Practice Location Address
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Address Line | 1227 W DEVON AVE
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City | CHICAGO
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State | IL
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Zip | 60660-1403
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Country | US
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Telephone | 773-359-3505
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Fax |
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Provider Business Mailing Address
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Address Line | 6427 N MAGNOLIA AVE
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City | CHICAGO
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State | IL
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Zip | 60626-5305
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Country | US
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Telephone | 773-359-3505
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Fax | 312-489-8138
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 150108430
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License Number State | IL
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