Healthcare Provider Details

I. General information

NPI: 1689942831
Provider Name (Legal Business Name): DEANNE MARIE WOLTER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 04/08/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 CARPENTER AVE
PLAINFIELD IL
60586-5943
US

IV. Provider business mailing address

2155 CARPENTER AVE
PLAINFIELD IL
60586-5943
US

V. Phone/Fax

Practice location:
  • Phone: 815-909-6586
  • Fax:
Mailing address:
  • Phone: 815-909-6586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180009211
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.006643
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: