Provider Demographics
NPI:1790068443
Name:DI MINERVINO, IRENE (DT)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:DI MINERVINO
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 ELM ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3368
Mailing Address - Country:US
Mailing Address - Phone:224-592-5862
Mailing Address - Fax:888-491-5663
Practice Address - Street 1:1208 ELM ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3368
Practice Address - Country:US
Practice Address - Phone:224-592-5862
Practice Address - Fax:888-491-5663
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIP25370711P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist