Healthcare Provider Details

I. General information

NPI: 1548016215
Provider Name (Legal Business Name): RICHARD TYLER CIPRIANO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5117B MAIN ST STE 5
DOWNERS GROVE IL
60515-4602
US

IV. Provider business mailing address

5117B MAIN ST STE 5
DOWNERS GROVE IL
60515-4602
US

V. Phone/Fax

Practice location:
  • Phone: 630-426-9719
  • Fax:
Mailing address:
  • Phone: 630-426-9719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number149.026011
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: