Healthcare Provider Details

I. General information

NPI: 1841722352
Provider Name (Legal Business Name): CONSTANCE B. MANSKE MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 09/26/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPT. OF PSYCHIATRY
EVANSTON IL
60201-1718
US

IV. Provider business mailing address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-425-6400
  • Fax:
Mailing address:
  • Phone: 479-826-7108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178012458
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180012763
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: