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General NPI Number Information
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NPI Number | 1437562501
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Entity Type | Organization
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Legal Business Name | VICKY COSTAKIS, LCPC LLC
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Dates
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Enumeration Date | 06/06/2014
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Last Update Date | 06/06/2014
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Provider Practice Location Address
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Address Line | 60 REVERE DR
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City | NORTHBROOK
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State | IL
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Zip | 60062-1563
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Country | US
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Telephone | 847-644-5133
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 GREENWOOD AVE
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City | WILMETTE
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State | IL
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Zip | 60091-1620
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Country | US
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Telephone | 847-256-6510
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | VICTORIA A COSTAKIS
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Credential | LCPC
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Telephone | 847-644-5133
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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 | 180.009161
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License Number State | IL
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