Healthcare Provider Details

I. General information

NPI: 1275018491
Provider Name (Legal Business Name): EMILY PETERS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25480 W CEDAR CREST LN
LAKE VILLA IL
60046-9744
US

IV. Provider business mailing address

25480 W CEDAR CREST LN
LAKE VILLA IL
60046-8256
US

V. Phone/Fax

Practice location:
  • Phone: 847-356-8205
  • Fax:
Mailing address:
  • Phone: 847-356-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178013112
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: