Healthcare Provider Details

I. General information

NPI: 1750830857
Provider Name (Legal Business Name): EMILY CISZEWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4823 N HOYNE AVE UNIT 1
CHICAGO IL
60625-1407
US

IV. Provider business mailing address

4823 N HOYNE AVE UNIT 1
CHICAGO IL
60625-1407
US

V. Phone/Fax

Practice location:
  • Phone: 585-732-6016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-22593
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1816097
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: