=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639415508
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER LEIGH LCPC, ATR-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2012
-----------------------------------------------------
Last Update Date | 10/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5536 S EVERETT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-643-6259
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1430 ELMWOOD AVE APT 1W
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-6525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-593-3159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180.007742
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------