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General NPI Number Information
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NPI Number | 1811584261
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Entity Type | Individual
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Provider Name | CORLISS IVY LCPC
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Gender | Female
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Dates
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Enumeration Date | 12/30/2020
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Last Update Date | 12/09/2021
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Provider Practice Location Address
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Address Line | 2520 ELISHA AVE
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City | ZION
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State | IL
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Zip | 60099
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Country | US
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Telephone | 224-707-0146
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Fax |
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Provider Business Mailing Address
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Address Line | 206 CEDAR AVE UNIT 664
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City | LAKE VILLA
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State | IL
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Zip | 60046-4629
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Country | US
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Telephone | 847-912-4991
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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 | 180.009200
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License Number State | IL
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