=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861166506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK MILAZZO LCPC LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2021
-----------------------------------------------------
Last Update Date | 08/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4611 N RAVENSWOOD AVE STE 205
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-7577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-373-1577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4611 N RAVENSWOOD AVE STE 205
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-7577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-373-1577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK MILAZZO
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 847-373-1577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------