Healthcare Provider Details

I. General information

NPI: 1164273363
Provider Name (Legal Business Name): DIANE ZAVALA M.A, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 STONEGATE RD STE 102
ALGONQUIN IL
60102-5614
US

IV. Provider business mailing address

111 S BUTRICK ST
WAUKEGAN IL
60085-5305
US

V. Phone/Fax

Practice location:
  • Phone: 224-678-9180
  • Fax: 224-678-9369
Mailing address:
  • Phone: 224-656-2290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178020061
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178020061
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: