Provider Demographics
NPI:1437470846
Name:IMMERGLUCK, KIYA (LCPC)
Entity Type:Individual
Prefix:DR
First Name:KIYA
Middle Name:
Last Name:IMMERGLUCK
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 1:4200 N MARINE DR
Mailing Address - Street 2:#405
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1743
Mailing Address - Country:US
Mailing Address - Phone:773-880-5492
Mailing Address - Fax:
Practice Address - Street 1:4200 N MARINE DR
Practice Address - Street 2:#405
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1743
Practice Address - Country:US
Practice Address - Phone:773-880-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-20
Last Update Date:2010-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor