Healthcare Provider Details

I. General information

NPI: 1245176999
Provider Name (Legal Business Name): ELYSE MARIE WISNIEWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N MICHIGAN AVE STE 450
CHICAGO IL
60601-7939
US

IV. Provider business mailing address

5915 N VIRGINIA AVE APT 2
CHICAGO IL
60659-3722
US

V. Phone/Fax

Practice location:
  • Phone: 708-628-7645
  • Fax:
Mailing address:
  • Phone: 312-420-3866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178020745
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: