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
Certification Date: 2021-02-09
Details
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NPI | 1811584261 | ||||||||
Enumeration Date | 2020-12-30 | ||||||||
NPI Type | NPI-1 Individual | ||||||||
Sole Proprietor | YES | ||||||||
Status | Active | ||||||||
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: | ||||||||
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