Provider Demographics
NPI:1669276242
Name:DIETERLE, MALISSA/LISA LYNN (LCPC; CADC)
Entity type:Individual
Prefix:MS
First Name:MALISSA/LISA
Middle Name:LYNN
Last Name:DIETERLE
Suffix:
Gender:
Credentials:LCPC; CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 N WESTERN AVE UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-6224
Mailing Address - Country:US
Mailing Address - Phone:773-251-5922
Mailing Address - Fax:
Practice Address - Street 1:1005 N WESTERN AVE UNIT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-6224
Practice Address - Country:US
Practice Address - Phone:773-251-5922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18283101YA0400X
IL180-003908101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)