Healthcare Provider Details

I. General information

NPI: 1689121428
Provider Name (Legal Business Name): CARLA RUTH LAURY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W GOLF RD STE 59B
ARLINGTON HEIGHTS IL
60005-3923
US

IV. Provider business mailing address

835 PEARSON ST APT 405
DES PLAINES IL
60016-6409
US

V. Phone/Fax

Practice location:
  • Phone: 847-305-1360
  • Fax:
Mailing address:
  • Phone: 847-431-5077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178012055
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: