Healthcare Provider Details

I. General information

NPI: 1316486194
Provider Name (Legal Business Name): ALYSE MALMBORG MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 N WESTERN AVE
CHICAGO IL
60647
US

IV. Provider business mailing address

2155 W BELMONT AVE # 1071
CHICAGO IL
60618-6471
US

V. Phone/Fax

Practice location:
  • Phone: 773-524-2685
  • Fax:
Mailing address:
  • Phone: 773-524-2685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180010265
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: