Healthcare Provider Details

I. General information

NPI: 1023136314
Provider Name (Legal Business Name): MARYSUE MASTEY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE SUITE 1002
CHICAGO IL
60602-3402
US

IV. Provider business mailing address

12 GRANDVIEW CT
ALGONQUIN IL
60102-1993
US

V. Phone/Fax

Practice location:
  • Phone: 847-302-8647
  • Fax:
Mailing address:
  • Phone: 847-302-8647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number30435
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-001787
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: