Provider Demographics
NPI:1750857942
Name:PLEDGER, MYRNA (LCPC)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:PLEDGER
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 1:259 W 104TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-2513
Mailing Address - Country:US
Mailing Address - Phone:708-357-9495
Mailing Address - Fax:
Practice Address - Street 1:259 W. 104TH PL.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628
Practice Address - Country:US
Practice Address - Phone:708-357-9495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006251101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.006251OtherSTATE LICENSE