Healthcare Provider Details

I. General information

NPI: 1396169637
Provider Name (Legal Business Name): MARY ANN RUTH MONAHAN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS MARY ANN RUTH PUSATERI

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 W. 35TH STREET 1ST FLOOR
CHICAGO IL
60616
US

IV. Provider business mailing address

1717 SOUTH PRAIRIE AVENUE #1004
CHICAGO IL
60616
US

V. Phone/Fax

Practice location:
  • Phone: 312-339-1749
  • Fax: 773-254-8944
Mailing address:
  • Phone: 312-339-1749
  • Fax: 773-254-8944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.004579
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: