Provider Demographics
NPI:1528774619
Name:MIMBELA, DENISE D
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:D
Last Name:MIMBELA
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 1:1925 N WOLCOTT AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1072
Mailing Address - Country:US
Mailing Address - Phone:915-258-3164
Mailing Address - Fax:
Practice Address - Street 1:1657 W CORTLAND ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1119
Practice Address - Country:US
Practice Address - Phone:847-486-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician