Healthcare Provider Details

I. General information

NPI: 1629593231
Provider Name (Legal Business Name): ANNA LOBANOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8311 ROOSEVELT RD
FOREST PARK IL
60130-2529
US

IV. Provider business mailing address

8311 ROOSEVELT RD
FOREST PARK IL
60130-2529
US

V. Phone/Fax

Practice location:
  • Phone: 847-962-8413
  • Fax: 630-810-9193
Mailing address:
  • Phone: 847-962-8413
  • Fax: 630-810-9193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.004417
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: