Healthcare Provider Details

I. General information

NPI: 1760098800
Provider Name (Legal Business Name): AMBER MARIE HEGEWALD LCPC, CCTP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3166 N LINCOLN AVE STE 217
CHICAGO IL
60657-3119
US

IV. Provider business mailing address

8015 S OGLESBY AVE
CHICAGO IL
60617-1134
US

V. Phone/Fax

Practice location:
  • Phone: 708-406-9870
  • Fax:
Mailing address:
  • Phone: 773-369-9902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.015989
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.016332
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: