Healthcare Provider Details

I. General information

NPI: 1073624243
Provider Name (Legal Business Name): NATALEE ROSE MITROVICH MA, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NATALEE SERPICO, GRCIC

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S MAIN ST
WAUCONDA IL
60084-1825
US

IV. Provider business mailing address

109 S MAIN ST
WAUCONDA IL
60084-1825
US

V. Phone/Fax

Practice location:
  • Phone: 224-818-4432
  • Fax:
Mailing address:
  • Phone: 224-818-4432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180004835
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-004835
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: