Healthcare Provider Details

I. General information

NPI: 1639636228
Provider Name (Legal Business Name): ANTHONY CRISANTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6502 JOLIET RD STE 201
COUNTRYSIDE IL
60525-4682
US

IV. Provider business mailing address

2749 S HILLOCK AVE
CHICAGO IL
60608-5729
US

V. Phone/Fax

Practice location:
  • Phone: 708-215-8400
  • Fax:
Mailing address:
  • Phone: 872-236-6773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.022095
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: