Provider Demographics
NPI:1003580663
Name:AMPHORA COUNSELING, PLLC
Entity Type:Organization
Organization Name:AMPHORA COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:224-349-2594
Mailing Address - Street 1:3205 N WILKE RD STE 102C
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-0004
Mailing Address - Country:US
Mailing Address - Phone:224-349-2594
Mailing Address - Fax:224-350-8500
Practice Address - Street 1:3205 N WILKE RD STE 102C
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-0004
Practice Address - Country:US
Practice Address - Phone:224-349-2594
Practice Address - Fax:224-350-8500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-05
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1578069506OtherLICENSE