Provider Demographics
NPI:1063784890
Name:HEREDIA-CARMONA, JOSETTE (LCSW)
Entity type:Individual
Prefix:
First Name:JOSETTE
Middle Name:
Last Name:HEREDIA-CARMONA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JOSETTE
Other - Middle Name:
Other - Last Name:HEREDIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:6918 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3334
Mailing Address - Country:US
Mailing Address - Phone:708-745-5277
Mailing Address - Fax:708-795-4834
Practice Address - Street 1:6918 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3334
Practice Address - Country:US
Practice Address - Phone:708-745-5277
Practice Address - Fax:708-795-4834
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490103441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical