Provider Demographics
NPI:1902623549
Name:BECERRA-MENESES, CARLOS (NP)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:BECERRA-MENESES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 W HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3106
Mailing Address - Country:US
Mailing Address - Phone:312-942-4500
Mailing Address - Fax:312-942-2380
Practice Address - Street 1:1127 N OAKLEY BLVD FL 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-3507
Practice Address - Country:US
Practice Address - Phone:312-770-3320
Practice Address - Fax:312-770-2557
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.030927363LP0808X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program