Healthcare Provider Details

I. General information

NPI: 1124301932
Provider Name (Legal Business Name): LEATRICE D ALLEN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E 79TH ST
CHICAGO IL
60619-2302
US

IV. Provider business mailing address

16603 PAULINA ST
MARKHAM IL
60428-5849
US

V. Phone/Fax

Practice location:
  • Phone: 773-487-0515
  • Fax: 773-487-0525
Mailing address:
  • Phone: 708-333-8144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180003101
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: