Provider Demographics
NPI:1790868321
Name:DE LA ROCA-VELEZ, LETICIA (LCSW)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:DE LA ROCA-VELEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W. FULTON STREET
Mailing Address - Street 2:200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661
Mailing Address - Country:US
Mailing Address - Phone:773-526-2200
Mailing Address - Fax:
Practice Address - Street 1:3229-43 W. 47TH PLACE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632
Practice Address - Country:US
Practice Address - Phone:773-254-6044
Practice Address - Fax:773-254-6115
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0113311041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1790868321Medicaid
Q43560Medicare ID - Type Unspecified