Healthcare Provider Details

I. General information

NPI: 1558455170
Provider Name (Legal Business Name): MARLENE KRUPA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 W 68TH STREET
CHICAGO IL
60629
US

IV. Provider business mailing address

13360 AVENUE M
CHICAGO IL
60633
US

V. Phone/Fax

Practice location:
  • Phone: 708-991-9002
  • Fax: 708-991-9003
Mailing address:
  • Phone: 773-646-2099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number71006290
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: