Provider Demographics
NPI:1275086670
Name:CACEDA, ALICE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:CACEDA
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 1:605 HINMAN AVE
Mailing Address - Street 2:BSMT
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-4625
Mailing Address - Country:US
Mailing Address - Phone:815-388-3154
Mailing Address - Fax:
Practice Address - Street 1:1431 N CLAREMONT AVE
Practice Address - Street 2:2ND FLOOR PAVILION
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1702
Practice Address - Country:US
Practice Address - Phone:312-633-5890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362235165Medicaid