Provider Demographics
NPI:1265117451
Name:LATIF, SURIYYA AZRA MARYUM
Entity type:Individual
Prefix:MRS
First Name:SURIYYA
Middle Name:AZRA MARYUM
Last Name:LATIF
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 1:3002 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-2321
Mailing Address - Country:US
Mailing Address - Phone:847-377-8618
Mailing Address - Fax:847-984-5676
Practice Address - Street 1:3002 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2321
Practice Address - Country:US
Practice Address - Phone:847-377-8618
Practice Address - Fax:847-984-5676
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251B00000XAgenciesCase Management
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility