Provider Demographics
NPI:1114259819
Name:MCCARGO, ANASTASIA MAZZULLA
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:MAZZULLA
Last Name:MCCARGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1979 N MILL ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1200
Mailing Address - Country:US
Mailing Address - Phone:630-428-2344
Mailing Address - Fax:630-428-2308
Practice Address - Street 1:1979 N MILL ST
Practice Address - Street 2:SUITE 211
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1200
Practice Address - Country:US
Practice Address - Phone:630-428-2344
Practice Address - Fax:630-428-2308
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006543101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional