Provider Demographics
NPI:1174853881
Name:CARDOSO, LETICIA SOUZA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:SOUZA
Last Name:CARDOSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LETICIA
Other - Middle Name:CARDOSO
Other - Last Name:KRASNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6227 N WASHTENAW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-2617
Mailing Address - Country:US
Mailing Address - Phone:847-347-6732
Mailing Address - Fax:
Practice Address - Street 1:6227 N WASHTENAW AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-2617
Practice Address - Country:US
Practice Address - Phone:847-347-6732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2010-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst