Provider Demographics
NPI:1679120851
Name:MAZZENGA, ALISSA (MA, LMHC, LCPC)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:MAZZENGA
Suffix:
Gender:F
Credentials:MA, LMHC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 N CLARK ST # 1160
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4620
Mailing Address - Country:US
Mailing Address - Phone:847-567-7888
Mailing Address - Fax:
Practice Address - Street 1:1770 WEST BERTEAU AVENUE SUITE 302A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:847-567-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60947049101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health