Healthcare Provider Details

I. General information

NPI: 1124516083
Provider Name (Legal Business Name): CARLI M CAMPBELL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N MICHIGAN AVE STE 201
CHICAGO IL
60601-7940
US

IV. Provider business mailing address

2240 W FARRAGUT AVE
CHICAGO IL
60625-0008
US

V. Phone/Fax

Practice location:
  • Phone: 312-819-7381
  • Fax:
Mailing address:
  • Phone: 262-424-6409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180013047
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: