Provider Demographics
NPI:1356957484
Name:DICOSOLA, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:DICOSOLA
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 1:5254 S DORCHESTER AVE APT 803
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-6003
Mailing Address - Country:US
Mailing Address - Phone:630-935-7434
Mailing Address - Fax:
Practice Address - Street 1:410 S MICHIGAN AVE STE 928
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1399
Practice Address - Country:US
Practice Address - Phone:312-248-3190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178013565101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health