Provider Demographics
NPI:1962631010
Name:UNIVERSITY OF ILLINOIS
Entity Type:Organization
Organization Name:UNIVERSITY OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VISITING STAFF PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARISELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUERTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-413-1741
Mailing Address - Street 1:1747 W ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1264
Mailing Address - Country:US
Mailing Address - Phone:312-413-1741
Mailing Address - Fax:
Practice Address - Street 1:1747 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1264
Practice Address - Country:US
Practice Address - Phone:312-413-1741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007706103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty