Provider Demographics
NPI:1457133175
Name:PUTHENPURACKAL, ROSE MATHEW (LSW)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MATHEW
Last Name:PUTHENPURACKAL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 S HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4719
Mailing Address - Country:US
Mailing Address - Phone:630-396-0207
Mailing Address - Fax:
Practice Address - Street 1:211 E LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2886
Practice Address - Country:US
Practice Address - Phone:630-446-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.110730101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health