Provider Demographics
NPI:1558455170
Name:KRUPA, MARLENE (PSYD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:KRUPA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13360 AVENUE M
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60633
Mailing Address - Country:US
Mailing Address - Phone:773-646-2099
Mailing Address - Fax:
Practice Address - Street 1:2701 W 68TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629
Practice Address - Country:US
Practice Address - Phone:708-991-9002
Practice Address - Fax:708-991-9003
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71006290103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632081OtherBLUE CROSS & BLUE SHIELD
IL01632081OtherBLUE CROSS & BLUE SHIELD