Healthcare Provider Details

I. General information

NPI: 1497388672
Provider Name (Legal Business Name): MARISSA MUNOZ LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6447 CERMAK RD
BERWYN IL
60402-2311
US

IV. Provider business mailing address

1429 N KOLIN AVE
CHICAGO IL
60651-1740
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax:
Mailing address:
  • Phone: 773-676-5496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.015686
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: