Provider Demographics
NPI:1437529625
Name:CAMACHO MEDINA, EUSEBIO ENRIQUE (MSW, LSW MASTERS)
Entity Type:Individual
Prefix:MR
First Name:EUSEBIO
Middle Name:ENRIQUE
Last Name:CAMACHO MEDINA
Suffix:
Gender:M
Credentials:MSW, LSW MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-2403
Mailing Address - Country:US
Mailing Address - Phone:219-689-6125
Mailing Address - Fax:
Practice Address - Street 1:2720 S RIVER RD STE 246
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-4111
Practice Address - Country:US
Practice Address - Phone:219-766-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1501056431041C0700X
IN99068963A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1316027998Medicaid