=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649493941
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP MARK LICATA LCPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 JORIE BLVD SUITE 48
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-2214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-951-0338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18557 W COUNTRY LN
-----------------------------------------------------
City | GRAYSLAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60030-2219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-231-4056
-----------------------------------------------------
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 | 180004784
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------