Provider Demographics
NPI:1558890566
Name:MALETICH, CARLY (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MALETICH
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 W BIRCHWOOD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1856
Mailing Address - Country:US
Mailing Address - Phone:731-227-2278
Mailing Address - Fax:
Practice Address - Street 1:600 DAVIS ST FL 3E
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4488
Practice Address - Country:US
Practice Address - Phone:731-227-2278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178009780101YM0800X
IL180.011042101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty