=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821593864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. MARY AMY ESPOSITO-USTERBOWSKI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2018
-----------------------------------------------------
Last Update Date | 03/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9907 S HAMILTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-259-4994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9907 S HAMILTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-259-4994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 2020054
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------