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Provider Information for 1811584261


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CORLISS IVY LCPC


Sex: Female

NPI: 1811584261
Last Updated: 2021-12-09
Certification Date: 2021-02-09

Details

NameValue
NPI1811584261
Enumeration Date2020-12-30
NPI TypeNPI-1 Individual
Sole ProprietorYES
StatusActive
Mailing Address 206 CEDAR AVE UNIT 664
LAKE VILLA, IL 60046-4629
United States

Phone: 847-912-4991 | Fax:
 
Primary Practice Address 2520 ELISHA AVE
ZION, IL 60099
United States

Phone: 224-707-0146 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 101YP2500X - Counselor - ProfessionalIL180.009200