Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YM0800X | Mental Health Counselor | ||
Y | 1041C0700X | Clinical Social Worker | 149019574 | IL |
NPI | 1003204686 |
---|---|
Provider Name | Silvia Diaz-Ponce |
First Address | Chicago, IL 60622-5646 |
Second Address | Chicago, IL 60647-5247 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2015 |
Last Update Date | 14/02/2019 |