Healthcare Provider Details

I. General information

NPI: 1124616198
Provider Name (Legal Business Name): CHANTAL DIPRIMA LCPC, ATR-P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHANTAL GILBERT LPC

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8311 ROOSEVELT RD
FOREST PARK IL
60130-2529
US

IV. Provider business mailing address

5538 W ROSCOE ST
CHICAGO IL
60641-4143
US

V. Phone/Fax

Practice location:
  • Phone: 708-771-7000
  • Fax:
Mailing address:
  • Phone: 925-360-9838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180013296
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: