Provider Demographics
NPI:1669465340
Name:RE, MARIELLEN M (LCSW/CADC)
Entity Type:Individual
Prefix:
First Name:MARIELLEN
Middle Name:M
Last Name:RE
Suffix:
Gender:F
Credentials:LCSW/CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 W ALGONQUIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-3575
Mailing Address - Country:US
Mailing Address - Phone:847-854-8995
Mailing Address - Fax:847-658-0787
Practice Address - Street 1:1303 W ALGONQUIN RD
Practice Address - Street 2:
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-3575
Practice Address - Country:US
Practice Address - Phone:847-854-8995
Practice Address - Fax:847-658-0787
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical