Provider Demographics
NPI:1326319377
Name:KATES, MARISSA PATRICE (MSW)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:PATRICE
Last Name:KATES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 N WOLCOTT AVE
Mailing Address - Street 2:UNIT 2B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 N WOLCOTT AVE
Practice Address - Street 2:UNIT 2B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2075
Practice Address - Country:US
Practice Address - Phone:847-602-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150013469104100000X
174400000X, 222Q00000X
IL149.0163521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No174400000XOther Service ProvidersSpecialist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist