Provider Demographics
NPI:1376147256
Name:DE LA ROSA, LOURDES (M ED)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 FAIRLAWN DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60073-3111
Mailing Address - Country:US
Mailing Address - Phone:224-770-0045
Mailing Address - Fax:
Practice Address - Street 1:701 N KRAMER AVE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-1943
Practice Address - Country:US
Practice Address - Phone:630-561-2075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty