Provider Demographics
NPI:1093606766
Name:SIDA SOLIS, LUIS ANGEL
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ANGEL
Last Name:SIDA SOLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2559 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2138
Mailing Address - Country:US
Mailing Address - Phone:708-654-4704
Mailing Address - Fax:
Practice Address - Street 1:2559 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2138
Practice Address - Country:US
Practice Address - Phone:708-654-4704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.284465183700000X
ILRBT-24-376715106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No183700000XPharmacy Service ProvidersPharmacy Technician