Provider Demographics
NPI:1558478883
Name:SPINABELLA, MARY ALICE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALICE
Last Name:SPINABELLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ALICE
Other - Last Name:POLCYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1560 SCHUMACHER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BOLING BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-3250
Mailing Address - Country:US
Mailing Address - Phone:630-771-1935
Mailing Address - Fax:
Practice Address - Street 1:62 WEST WASHINGTON
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432
Practice Address - Country:US
Practice Address - Phone:815-722-4384
Practice Address - Fax:815-722-4390
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490051541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9023Medicaid
IL612561Medicare UPIN
ILL33706Medicare ID - Type Unspecified