Healthcare Provider Details

I. General information

NPI: 1649814195
Provider Name (Legal Business Name): MARY (KATIE) KATHLEEN REAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 W IRVING PARK RD
CHICAGO IL
60641-2935
US

IV. Provider business mailing address

4537 N LEAVITT ST APT 1
CHICAGO IL
60625-1673
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-4444
  • Fax:
Mailing address:
  • Phone: 574-276-5018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.014636
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: