Provider Demographics
NPI:1790324515
Name:ACEVEDO, ILSE MIRELLE I
Entity Type:Individual
Prefix:
First Name:ILSE
Middle Name:MIRELLE
Last Name:ACEVEDO
Suffix:I
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 1:4211 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4625
Mailing Address - Country:US
Mailing Address - Phone:773-905-2539
Mailing Address - Fax:
Practice Address - Street 1:451 N LASALLE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654
Practice Address - Country:US
Practice Address - Phone:312-893-7216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.021776104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker