Provider Demographics
NPI:1326616467
Name:DEREMER, MARK ANTHONY (LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:DEREMER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:MR
Other - First Name:MAJID
Other - Middle Name:MARK
Other - Last Name:GILVAIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1345 W LUNT AVE APT 510
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3020
Mailing Address - Country:US
Mailing Address - Phone:312-520-3313
Mailing Address - Fax:
Practice Address - Street 1:180 N MICHIGAN AVE STE 410
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7488
Practice Address - Country:US
Practice Address - Phone:312-520-3313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.014323101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional