Healthcare Provider Details

I. General information

NPI: 1356038848
Provider Name (Legal Business Name): LYNETT MARIE KOPEC-MOHR ATR, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3534 LAKE AVE # 200
WILMETTE IL
60091-1063
US

IV. Provider business mailing address

9036 MANSFIELD AVE
MORTON GROVE IL
60053-2441
US

V. Phone/Fax

Practice location:
  • Phone: 547-386-6560
  • Fax:
Mailing address:
  • Phone: 847-682-8386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180002646
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: