Healthcare Provider Details

I. General information

NPI: 1437718632
Provider Name (Legal Business Name): MEREDITH YEBRA LCPC, ART-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 N CLARK ST # 1203
CHICAGO IL
60640-4620
US

IV. Provider business mailing address

4610 N CLARK ST # 1203
CHICAGO IL
60640-4620
US

V. Phone/Fax

Practice location:
  • Phone: 312-278-7628
  • Fax:
Mailing address:
  • Phone: 312-278-7628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number178014741
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180014143
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: