Healthcare Provider Details

I. General information

NPI: 1346075249
Provider Name (Legal Business Name): ELLIS HEYEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E MAIN ST STE 201
ST CHARLES IL
60174-2205
US

IV. Provider business mailing address

1121 E MAIN ST STE 201
ST CHARLES IL
60174-2205
US

V. Phone/Fax

Practice location:
  • Phone: 630-699-5518
  • Fax:
Mailing address:
  • Phone: 630-699-5518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.020542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: