Healthcare Provider Details

I. General information

NPI: 1760314850
Provider Name (Legal Business Name): PAICHENCE MAZE LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4043 N RAVENSWOOD AVE STE 301
CHICAGO IL
60613-5683
US

IV. Provider business mailing address

1735 W ALBION AVE # 1
CHICAGO IL
60626-3917
US

V. Phone/Fax

Practice location:
  • Phone: 312-967-4669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.018295
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: