Provider Demographics
NPI:1568544468
Name:DEPETRIZZI, JOAN G
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:G
Last Name:DEPETRIZZI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6250 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-3861
Mailing Address - Country:US
Mailing Address - Phone:773-622-6218
Mailing Address - Fax:773-622-7440
Practice Address - Street 1:6250 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-3861
Practice Address - Country:US
Practice Address - Phone:773-622-6218
Practice Address - Fax:773-622-7440
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490040031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL359600Medicare ID - Type Unspecified