Provider Demographics
NPI:1528772407
Name:FINAZZO, MAGDALYN
Entity type:Individual
Prefix:
First Name:MAGDALYN
Middle Name:
Last Name:FINAZZO
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 1:1640 W ROOSEVELT RD # DHSP568
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1316
Mailing Address - Country:US
Mailing Address - Phone:312-996-7988
Mailing Address - Fax:312-413-1593
Practice Address - Street 1:1640 W ROOSEVELT RD # DHSP103
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1316
Practice Address - Country:US
Practice Address - Phone:312-996-7988
Practice Address - Fax:312-413-1593
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-22-218191106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILBACB635566OtherBACB
ILRBT-22-218191OtherBACB