Provider Demographics
NPI:1821593864
Name:ESPOSITO-USTERBOWSKI, MARY AMY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:AMY
Last Name:ESPOSITO-USTERBOWSKI
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 1:9907 S HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1813
Mailing Address - Country:US
Mailing Address - Phone:708-259-4994
Mailing Address - Fax:
Practice Address - Street 1:9907 S HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1813
Practice Address - Country:US
Practice Address - Phone:708-259-4994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2020054103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool