Healthcare Provider Details

I. General information

NPI: 1235843392
Provider Name (Legal Business Name): SARINA DIMASO PEER SUPPORT SPECIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 W MONTROSE AVE
CHICAGO IL
60641-2016
US

IV. Provider business mailing address

4320 W MONTROSE AVE
CHICAGO IL
60641-2016
US

V. Phone/Fax

Practice location:
  • Phone: 773-883-9100
  • Fax: 773-883-0005
Mailing address:
  • Phone: 177-388-3910
  • Fax: 773-883-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: