Healthcare Provider Details

I. General information

NPI: 1700357167
Provider Name (Legal Business Name): COREY LARISCY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ILLINOIS BLVD STE 107
HOFFMAN ESTATES IL
60169-3314
US

IV. Provider business mailing address

1 ILLINOIS BLVD STE 107
HOFFMAN ESTATES IL
60169-3314
US

V. Phone/Fax

Practice location:
  • Phone: 847-844-6212
  • Fax:
Mailing address:
  • Phone: 847-844-6212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number178.014320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: