Healthcare Provider Details

I. General information

NPI: 1366137010
Provider Name (Legal Business Name): MOLLY R MEJIA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/11/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5097 N ELSTON AVE STE 305
CHICAGO IL
60630-2460
US

IV. Provider business mailing address

1587 COVE DR
PROSPECT HEIGHTS IL
60070-1910
US

V. Phone/Fax

Practice location:
  • Phone: 773-683-2781
  • Fax:
Mailing address:
  • Phone: 224-223-9817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.007801
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: