Healthcare Provider Details

I. General information

NPI: 1790068443
Provider Name (Legal Business Name): IRENE DI MINERVINO DT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 ELM ST
PARK RIDGE IL
60068-3368
US

IV. Provider business mailing address

1208 ELM ST
PARK RIDGE IL
60068-3368
US

V. Phone/Fax

Practice location:
  • Phone: 224-592-5862
  • Fax: 888-491-5663
Mailing address:
  • Phone: 224-592-5862
  • Fax: 888-491-5663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberIP25370711P
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: