Provider Demographics
NPI:1093151250
Name:FLEMING, MARY ELLEN (RN,MA LPC QMHP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:FLEMING
Suffix:
Gender:F
Credentials:RN,MA LPC QMHP
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Mailing Address - Street 1:3805 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:WONDER LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60097-9456
Mailing Address - Country:US
Mailing Address - Phone:815-814-2054
Mailing Address - Fax:815-759-7298
Practice Address - Street 1:4001 W DAYTON ST
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8377
Practice Address - Country:US
Practice Address - Phone:815-759-7058
Practice Address - Fax:815-759-7298
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL178.008617101YM0800X
IL041.229014163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362480845Medicaid