Provider Demographics
NPI:1538891114
Name:DIBENNARDI, MARISA (MA)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:DIBENNARDI
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 W BARRY AVE APT 9J
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5412
Mailing Address - Country:US
Mailing Address - Phone:708-476-9485
Mailing Address - Fax:
Practice Address - Street 1:533 W BARRY AVE APT 9J
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5412
Practice Address - Country:US
Practice Address - Phone:708-476-9485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017774101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL15653535Medicaid