Provider Demographics
NPI:1386466068
Name:ROSALES JUAREZ, SOFIA A
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:A
Last Name:ROSALES JUAREZ
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 1:4100 W 59TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4910
Mailing Address - Country:US
Mailing Address - Phone:262-885-7851
Mailing Address - Fax:
Practice Address - Street 1:1011 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1148
Practice Address - Country:US
Practice Address - Phone:708-918-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.020652101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional