Provider Demographics
NPI:1033607031
Name:ZISSMAN, MARK A (PSYD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ZISSMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1032
Mailing Address - Country:US
Mailing Address - Phone:630-717-2258
Mailing Address - Fax:
Practice Address - Street 1:222 S GREENLEAF ST STE 106
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5705
Practice Address - Country:US
Practice Address - Phone:847-356-8205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009193103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical