Provider Demographics
NPI:1407154628
Name:PERLONGO, MARY JOSEPHINE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JOSEPHINE
Last Name:PERLONGO
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616 WEST GOODMAN ST
Mailing Address - Street 2:#104
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630
Mailing Address - Country:US
Mailing Address - Phone:773-609-2884
Mailing Address - Fax:773-609-2884
Practice Address - Street 1:5616 W GOODMAN ST
Practice Address - Street 2:#104
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-4650
Practice Address - Country:US
Practice Address - Phone:773-609-2884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional