Healthcare Provider Details

I. General information

NPI: 1750674248
Provider Name (Legal Business Name): MARY ELLEN HEGEMEYER MS, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

666 RUSSEL COURT
WOODSTOCK IL
60098
US

IV. Provider business mailing address

666 RUSSEL COURT
WOODSTOCK IL
60098
US

V. Phone/Fax

Practice location:
  • Phone: 815-338-7749
  • Fax: 815-338-7728
Mailing address:
  • Phone: 815-338-7749
  • Fax: 815-338-7728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.002641
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: