Healthcare Provider Details

I. General information

NPI: 1447048426
Provider Name (Legal Business Name): ENSOLEILLE BEHAVIORAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 W IRVING PARK RD
CHICAGO IL
60613-3011
US

IV. Provider business mailing address

4861 W CATALPA AVE
CHICAGO IL
60630-1513
US

V. Phone/Fax

Practice location:
  • Phone: 708-943-7915
  • Fax:
Mailing address:
  • Phone: 773-430-8745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIAM DIALLO-FOFANA
Title or Position: NURSE PRACTITIONER
Credential: APRN/FPA
Phone: 708-943-7915