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General NPI Number Information
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NPI Number | 1790324515
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Entity Type | Individual
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Provider Name | ILSE MIRELLE ACEVEDO I
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Gender | Female
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Dates
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Enumeration Date | 12/26/2019
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Last Update Date | 12/26/2019
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Provider Practice Location Address
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Address Line | 451 N LASALLE
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City | CHICAGO
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State | IL
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Zip | 60654
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Country | US
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Telephone | 312-893-7216
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Fax |
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Provider Business Mailing Address
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Address Line | 4211 W 55TH ST
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City | CHICAGO
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State | IL
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Zip | 60632-4625
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Country | US
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Telephone | 773-905-2539
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Fax |
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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 | 149.021776
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License Number State | IL
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