Provider Demographics
NPI:1558599811
Name:GIANDONATO, KATHLEEN ANNA TRESSEL (MS, MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANNA TRESSEL
Last Name:GIANDONATO
Suffix:
Gender:F
Credentials:MS, MSW, LCSW
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANNA TRESSEL
Other - Last Name:ELLSWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1519 CUYLER AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1423
Mailing Address - Country:US
Mailing Address - Phone:773-766-7010
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1015
Practice Address - Country:US
Practice Address - Phone:773-766-7010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0129981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL984620Medicare PIN