Healthcare Provider Details

I. General information

NPI: 1114025434
Provider Name (Legal Business Name): MARREA A. WINNEGA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 W ROOSEVELT RD ROOM 155, M/C 747
CHICAGO IL
60608-1264
US

IV. Provider business mailing address

1747 W ROOSEVELT RD ROOM 155, M/C 747
CHICAGO IL
60608-1264
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-0357
  • Fax: 312-355-3634
Mailing address:
  • Phone: 312-996-0357
  • Fax: 312-355-3634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number071004663
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071004663
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1118506
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number071004663
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: