Healthcare Provider Details

I. General information

NPI: 1710444336
Provider Name (Legal Business Name): LAURA JEAN ALLEN LCPC, BC-DMT, GL-CMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA JEAN SPENCER

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 E COLUMBIA AVE
ELMHURST IL
60126-2441
US

IV. Provider business mailing address

260 E COLUMBIA AVE
ELMHURST IL
60126-2441
US

V. Phone/Fax

Practice location:
  • Phone: 773-802-4313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.008140
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: