Healthcare Provider Details

I. General information

NPI: 1821593864
Provider Name (Legal Business Name): MRS. MARY AMY ESPOSITO-USTERBOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9907 S HAMILTON AVE
CHICAGO IL
60643-1813
US

IV. Provider business mailing address

9907 S HAMILTON AVE
CHICAGO IL
60643-1813
US

V. Phone/Fax

Practice location:
  • Phone: 708-259-4994
  • Fax:
Mailing address:
  • Phone: 708-259-4994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2020054
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: