Healthcare Provider Details

I. General information

NPI: 1780129536
Provider Name (Legal Business Name): LATRICE ANNETTE MARIC PH.D., LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LATRICE ANNETTE DRAIN PH.D.

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E ERIE ST STE 520
CHICAGO IL
60611-2792
US

IV. Provider business mailing address

845 N KINGSBURY ST
CHICAGO IL
60610-9241
US

V. Phone/Fax

Practice location:
  • Phone: 630-428-7890
  • Fax:
Mailing address:
  • Phone: 312-796-7086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180015221
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: