Provider Demographics
NPI:1598911562
Name:OSUCH, MARISOL A (MA)
Entity Type:Individual
Prefix:MRS
First Name:MARISOL
Middle Name:A
Last Name:OSUCH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5341 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2817
Mailing Address - Country:US
Mailing Address - Phone:708-656-6430
Mailing Address - Fax:708-656-6591
Practice Address - Street 1:5341 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2817
Practice Address - Country:US
Practice Address - Phone:708-656-6430
Practice Address - Fax:708-656-6591
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-11
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362246705Medicaid
IL202591OtherMEDICARE
IL1617631OtherBLUE CROSS BLUE SHIELD