Provider Demographics
NPI:1477789865
Name:KORTH, MARY E (LCPC, CADC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:KORTH
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19730 E TWOMBLY RD
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-9621
Mailing Address - Country:US
Mailing Address - Phone:815-761-6709
Mailing Address - Fax:
Practice Address - Street 1:19730 E TWOMBLY RD
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-9621
Practice Address - Country:US
Practice Address - Phone:815-761-6709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-31
Last Update Date:2017-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12956101YA0400X
IL180.006198101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)