Provider Demographics
NPI:1619600533
Name:MILLIS, MARY KATHERINE (LCPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:MILLIS
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 1:21 W CHESTNUT ST APT 906
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3398
Mailing Address - Country:US
Mailing Address - Phone:630-272-9595
Mailing Address - Fax:
Practice Address - Street 1:2542 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5216
Practice Address - Country:US
Practice Address - Phone:224-355-5045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.013751101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional