Provider Demographics
NPI:1568215622
Name:MEJIA AGUILAR, EMELISSA
Entity Type:Individual
Prefix:
First Name:EMELISSA
Middle Name:
Last Name:MEJIA AGUILAR
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 1:2218 S LARAMIE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2818
Mailing Address - Country:US
Mailing Address - Phone:979-253-1895
Mailing Address - Fax:
Practice Address - Street 1:770 N HALSTED ST STE 105
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-7886
Practice Address - Country:US
Practice Address - Phone:312-298-9224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.020064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health