=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821630799
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANITA LOUISE DIERKS LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2019
-----------------------------------------------------
Last Update Date | 10/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9241 S IL ROUTE 31
-----------------------------------------------------
City | LAKE IN THE HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60156-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-346-6877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9241 S IL ROUTE 31
-----------------------------------------------------
City | LAKE IN THE HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60156-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-346-6877
-----------------------------------------------------
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 | 180.008143
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------