Provider Demographics
NPI:1942890439
Name:GUEVARA, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GUEVARA
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 1:1 E ERIE ST STE 525
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2980
Mailing Address - Country:US
Mailing Address - Phone:312-775-2045
Mailing Address - Fax:772-938-8512
Practice Address - Street 1:661 W LAKE ST STE 2S
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1034
Practice Address - Country:US
Practice Address - Phone:312-775-2045
Practice Address - Fax:773-938-8512
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490210991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical