Provider Demographics
NPI:1073729489
Name:GIACOMUZZI, MARIO PETER (PSYD PC)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:PETER
Last Name:GIACOMUZZI
Suffix:
Gender:M
Credentials:PSYD PC
Other - Prefix:MR
Other - First Name:MARIO
Other - Middle Name:
Other - Last Name:GIACOMUZZI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:GILBERTS
Mailing Address - State:IL
Mailing Address - Zip Code:60136-0082
Mailing Address - Country:US
Mailing Address - Phone:847-334-1476
Mailing Address - Fax:
Practice Address - Street 1:121 S WILKE RD
Practice Address - Street 2:SUITE 410
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1533
Practice Address - Country:US
Practice Address - Phone:847-334-1476
Practice Address - Fax:847-429-1890
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31623056OtherBLUE CROSS PROVIDER NUMBE