Healthcare Provider Details

I. General information

NPI: 1336903350
Provider Name (Legal Business Name): MARY GARZA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY KRUTZ LPC

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 DAKOTA ST STE A
CRYSTAL LAKE IL
60012-3744
US

IV. Provider business mailing address

650 DAKOTA ST STE A
CRYSTAL LAKE IL
60012-3744
US

V. Phone/Fax

Practice location:
  • Phone: 815-455-6000
  • Fax:
Mailing address:
  • Phone: 815-334-5018
  • Fax: 815-356-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178020279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: