Provider Demographics
NPI:1619535002
Name:AYALA, SERGIO (MDIV, MS, LMHC)
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:
Last Name:AYALA
Suffix:
Gender:M
Credentials:MDIV, MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 141ST ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46327-1221
Mailing Address - Country:US
Mailing Address - Phone:630-936-1839
Mailing Address - Fax:
Practice Address - Street 1:7601 S KOSTNER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-1126
Practice Address - Country:US
Practice Address - Phone:630-936-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL33810101YA0400X
IL178.010795101YP2500X
IA094835101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional