Provider Demographics
NPI:1417423195
Name:WHILE, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WHILE
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 1:3481 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-9151
Mailing Address - Country:US
Mailing Address - Phone:815-275-2827
Mailing Address - Fax:
Practice Address - Street 1:3481 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-9151
Practice Address - Country:US
Practice Address - Phone:815-275-2827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2020-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007886101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional