Provider Demographics
NPI:1174181820
Name:TRUJILLO, ILENE
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:
Last Name:TRUJILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 N 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:STONE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60165-1112
Mailing Address - Country:US
Mailing Address - Phone:708-244-4202
Mailing Address - Fax:
Practice Address - Street 1:1642 N 40TH AVE
Practice Address - Street 2:
Practice Address - City:STONE PARK
Practice Address - State:IL
Practice Address - Zip Code:60165-1112
Practice Address - Country:US
Practice Address - Phone:708-244-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician