Healthcare Provider Details

I. General information

NPI: 1780934372
Provider Name (Legal Business Name): ANGELA J CONNOR LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 E PATMORE ST
DIAMOND IL
60416-6031
US

IV. Provider business mailing address

1724 E PATMORE ST
DIAMOND IL
60416-6031
US

V. Phone/Fax

Practice location:
  • Phone: 815-582-6818
  • Fax:
Mailing address:
  • Phone: 815-582-6818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178007601
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: