MEDICARE: ANNETTE MANDEVILLE LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		IL
2	101YP2500X	Professional Counselor		IL

General Provider Information

NPI Number	:	1871705624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNETTE MANDEVILLE LCPC

Provider Business Mailing Address
First Line	:	5457 S EVERETT AVE
Second Line	:	2-B
City	:	CHICAGO
State	:	IL
Zip	:	60615-5945
Country	:	US
Telephone Number	:	773-501-9326
Fax Number	:

Provider Business Practice Location Address
First Line	:	5457 S EVERETT AVE
Second Line	:	2-B
City	:	CHICAGO
State	:	IL
Zip	:	60615-5945
Country	:	US
Telephone Number	:	773-501-9326
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	09/11/2025

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