Provider Demographics
NPI:1174271092
Name:EDGECOMBE, MATTLYN NICOLE (MA LLPC)
Entity Type:Individual
Prefix:
First Name:MATTLYN
Middle Name:NICOLE
Last Name:EDGECOMBE
Suffix:
Gender:F
Credentials:MA LLPC
Other - Prefix:
Other - First Name:MATTLYN
Other - Middle Name:NICOLE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1190 E ALGONQUIN RD
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-3084
Mailing Address - Country:US
Mailing Address - Phone:224-357-0540
Mailing Address - Fax:
Practice Address - Street 1:1190 E ALGONQUIN RD
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-3084
Practice Address - Country:US
Practice Address - Phone:224-357-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019845101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor