Provider Demographics
NPI:1336506484
Name:CARLI, DOMENICO
Entity Type:Individual
Prefix:
First Name:DOMENICO
Middle Name:
Last Name:CARLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N DEARBORN ST
Mailing Address - Street 2:#400
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3873
Mailing Address - Country:US
Mailing Address - Phone:312-191-6570
Mailing Address - Fax:
Practice Address - Street 1:650 N DEARBORN ST
Practice Address - Street 2:#400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3873
Practice Address - Country:US
Practice Address - Phone:312-291-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004286101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health