Healthcare Provider Details

I. General information

NPI: 1710441555
Provider Name (Legal Business Name): MARIANNE L COSTALES-ROMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 N WEBER RD STE 100
BOLINGBROOK IL
60440-1519
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 630-646-5777
  • Fax:
Mailing address:
  • Phone: 630-646-5777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149012137
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: