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General NPI Number Information
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NPI Number | 1023136314
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Entity Type | Individual
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Provider Name | MARYSUE MASTEY LCPC
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Gender | Female
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 06/24/2014
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Provider Practice Location Address
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Address Line | 30 N MICHIGAN AVE SUITE 1002
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City | CHICAGO
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State | IL
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Zip | 60602-3402
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Country | US
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Telephone | 847-302-8647
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Fax |
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Provider Business Mailing Address
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Address Line | 12 GRANDVIEW CT
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City | ALGONQUIN
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State | IL
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Zip | 60102-1993
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Country | US
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Telephone | 847-302-8647
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180-001787
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 30435
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License Number State | IL
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