Healthcare Provider Details

I. General information

NPI: 1508931163
Provider Name (Legal Business Name): MARK ANTHONY MACIUSZEK MA LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7424 ARCHER RD
SUMMIT IL
60501
US

IV. Provider business mailing address

1437 MORGAN AVENUE
LAGRANGE PARK IL
60526
US

V. Phone/Fax

Practice location:
  • Phone: 708-458-8228
  • Fax: 708-458-9177
Mailing address:
  • Phone: 708-354-2833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: