Healthcare Provider Details

I. General information

NPI: 1164165767
Provider Name (Legal Business Name): AVONLEA COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 IROQUOIS AVE STE 100
NAPERVILLE IL
60563-8537
US

IV. Provider business mailing address

1240 IROQUOIS AVE STE 100
NAPERVILLE IL
60563-8537
US

V. Phone/Fax

Practice location:
  • Phone: 630-473-8292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ELITZA LAUTERWASSER
Title or Position: OWNER
Credential: LCPC
Phone: 224-627-6038