Healthcare Provider Details

I. General information

NPI: 1639230618
Provider Name (Legal Business Name): MICHELLE ALANE MASBAUM LCPC, ATR-BC, CDVP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 HINMAN AVE APT 2
EVANSTON IL
60202-4446
US

IV. Provider business mailing address

744 HINMAN AVE APT 2
EVANSTON IL
60202-4446
US

V. Phone/Fax

Practice location:
  • Phone: 847-745-3036
  • Fax: 847-745-3096
Mailing address:
  • Phone: 847-745-3036
  • Fax: 847-745-3096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number05-003
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: