Provider Demographics
NPI:1124789284
Name:GIMENA, IRINA M (LCSW, CADC, CCM)
Entity type:Individual
Prefix:MRS
First Name:IRINA
Middle Name:M
Last Name:GIMENA
Suffix:
Gender:F
Credentials:LCSW, CADC, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 MARGUERITE ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1934
Mailing Address - Country:US
Mailing Address - Phone:184-733-4301
Mailing Address - Fax:
Practice Address - Street 1:212 S MARION ST STE 9
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-3159
Practice Address - Country:US
Practice Address - Phone:847-334-3015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL29631101YA0400X
IL4242224171M00000X
IL1490162411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty