Healthcare Provider Details

I. General information

NPI: 1619628450
Provider Name (Legal Business Name): ANITA MANDLEY LCPC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7514 KOSTNER AVE
SKOKIE IL
60076-3828
US

IV. Provider business mailing address

7514 KOSTNER AVE
SKOKIE IL
60076-3828
US

V. Phone/Fax

Practice location:
  • Phone: 312-509-2245
  • Fax:
Mailing address:
  • Phone: 312-509-2245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANITA A MANDLEY
Title or Position: OWNER
Credential: LCPC
Phone: 312-509-2245