=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194194332
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANIYYAH TAUFIQUE M.S., LCPC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2015
-----------------------------------------------------
Last Update Date | 10/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 REVERE DR STE 100
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-1590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-464-1711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4957 OAKTON STREET # 255
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-240-4265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | APC005092
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 178.012927
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180.012005
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180.012005
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------