Provider Demographics
NPI:1508590563
Name:GARCIA, DEVIN CISNEROS
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:CISNEROS
Last Name:GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 N LA SALLE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3751
Mailing Address - Country:US
Mailing Address - Phone:312-948-6993
Mailing Address - Fax:217-782-3991
Practice Address - Street 1:4725 N LARAMIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3607
Practice Address - Country:US
Practice Address - Phone:312-375-4664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL156951360Medicaid