MEDICARE: MARINA ANTONIA THEISEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	178.032738	IL

General Provider Information

NPI Number	:	1386572113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA ANTONIA THEISEN

Provider Business Mailing Address
First Line	:	10801 S WESTERN AVE STE 2B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-3223
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10801 S WESTERN AVE STE 2B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-3223
Country	:	US
Telephone Number	:	708-586-7357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2026
Last Update Date	:	05/12/2026

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Directions to “ MARINA ANTONIA THEISEN ” Practice Location

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