Provider Demographics
NPI:1083496285
Name:AMARYLLIS MIND, BODY, & SOUL COUNSELING
Entity Type:Organization
Organization Name:AMARYLLIS MIND, BODY, & SOUL COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LICAVOLI
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:314-397-1428
Mailing Address - Street 1:9626 RIDGE HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2319
Mailing Address - Country:US
Mailing Address - Phone:314-397-1428
Mailing Address - Fax:
Practice Address - Street 1:4509 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1524
Practice Address - Country:US
Practice Address - Phone:314-669-5060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty