Provider Demographics
NPI:1760061113
Name:CETINA, ALLISON
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:CETINA
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 1:1336 N DAMEN AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2298
Mailing Address - Country:US
Mailing Address - Phone:630-779-9222
Mailing Address - Fax:
Practice Address - Street 1:1416 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-0939
Practice Address - Country:US
Practice Address - Phone:630-779-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.104990104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150.104990OtherIDFPR