Healthcare Provider Details

I. General information

NPI: 1831499052
Provider Name (Legal Business Name): EAULY BRAUTIGAM LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18640 BELVIDERE ROAD
GRAYSLAKE IL
60030
US

IV. Provider business mailing address

2244 NICHOLS RD APT D
ARLINGTON HEIGHTS IL
60004-1149
US

V. Phone/Fax

Practice location:
  • Phone: 847-548-6000
  • Fax:
Mailing address:
  • Phone: 773-225-4832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.012335
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: