Provider Demographics
NPI:1558980995
Name:NEOFOTISTOS, ATHENA (LPC)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:NEOFOTISTOS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 W PARK AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3348
Mailing Address - Country:US
Mailing Address - Phone:630-884-9021
Mailing Address - Fax:
Practice Address - Street 1:180 W PARK AVE STE 150
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-3348
Practice Address - Country:US
Practice Address - Phone:630-884-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.014002101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional