Provider Demographics
NPI:1619954401
Name:FOOTLIK, JANICE B (MA LCPC NCC CCCJS NA)
Entity Type:Individual
Prefix:MISS
First Name:JANICE
Middle Name:B
Last Name:FOOTLIK
Suffix:
Gender:F
Credentials:MA LCPC NCC CCCJS NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 WELLINGTON CT
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4975
Mailing Address - Country:US
Mailing Address - Phone:847-866-9625
Mailing Address - Fax:847-328-6868
Practice Address - Street 1:2521 GROSS POINT RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4993
Practice Address - Country:US
Practice Address - Phone:847-866-9625
Practice Address - Fax:847-328-6868
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1020090103T00000X
A17526103T00000X
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0007607959OtherBLUE CROSS BLUE SHIELD
17526OtherNAFC PROVIDER
IL7481658OtherAETNA INS PROVIDER