Healthcare Provider Details

I. General information

NPI: 1093538258
Provider Name (Legal Business Name): MALARY MAGDELYN VANOVERBERGHE MHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

911 CHURCH ST
EVANSTON IL
60201
US

IV. Provider business mailing address

3829 N SOUTHPORT AVE
CHICAGO IL
60613-2879
US

V. Phone/Fax

Practice location:
  • Phone: 847-919-9096
  • Fax:
Mailing address:
  • Phone: 574-904-7095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: