Provider Demographics
NPI:1437718632
Name:RAQUE, MEREDITH (LCPC, ART)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:RAQUE
Suffix:
Gender:F
Credentials:LCPC, ART
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MICHIGAN AVE STE 424
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3844
Mailing Address - Country:US
Mailing Address - Phone:312-279-9981
Mailing Address - Fax:312-279-9981
Practice Address - Street 1:30 N MICHIGAN AVE STE 424
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3844
Practice Address - Country:US
Practice Address - Phone:312-279-9981
Practice Address - Fax:312-279-9981
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014741221700000X
IL180014143101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
22-090OtherATR REGISTRY
IL180014143OtherSTATE OF ILLINOIS