Healthcare Provider Details

I. General information

NPI: 1568134609
Provider Name (Legal Business Name): MEGAN LOUISE BUETIKOFER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 OAK CREEK DR
LOMBARD IL
60148-6408
US

IV. Provider business mailing address

991 OAK CREEK DR
LOMBARD IL
60148-6408
US

V. Phone/Fax

Practice location:
  • Phone: 331-425-8625
  • Fax:
Mailing address:
  • Phone: 331-425-8625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.011504
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: