Healthcare Provider Details

I. General information

NPI: 1104216530
Provider Name (Legal Business Name): DENISE MEGINNISS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 W BOUGHTON RD
BOLINGBROOK IL
60440-1892
US

IV. Provider business mailing address

440 W BOUGHTON RD
BOLINGBROOK IL
60440-1892
US

V. Phone/Fax

Practice location:
  • Phone: 888-542-2119
  • Fax: 630-863-7293
Mailing address:
  • Phone: 888-542-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.004419
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: