Healthcare Provider Details

I. General information

NPI: 1184085573
Provider Name (Legal Business Name): DANIELLE MARIE CICCONE- COUTRE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2016
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 CENTER ST STE C
GRAYSLAKE IL
60030-1645
US

IV. Provider business mailing address

11314 E RIVIERA DR
SPRING GROVE IL
60081-8146
US

V. Phone/Fax

Practice location:
  • Phone: 262-412-7302
  • Fax:
Mailing address:
  • Phone: 262-412-7302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071009251
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: