Provider Demographics
NPI:1740098854
Name:FORTUNE, ROSEMARIE CARMEL
Entity type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:CARMEL
Last Name:FORTUNE
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 1:4043 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5220
Mailing Address - Country:US
Mailing Address - Phone:847-791-2564
Mailing Address - Fax:
Practice Address - Street 1:5255 S STATE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-6303
Practice Address - Country:US
Practice Address - Phone:847-791-2564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2562569103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool