Provider Demographics
NPI:1760098800
Name:HEGEWALD, AMBER MARIE (LPC, CCTP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:MARIE
Last Name:HEGEWALD
Suffix:
Gender:F
Credentials:LPC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8015 S OGLESBY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1134
Mailing Address - Country:US
Mailing Address - Phone:773-369-9902
Mailing Address - Fax:
Practice Address - Street 1:3166 N LINCOLN AVE STE 217
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3119
Practice Address - Country:US
Practice Address - Phone:708-406-9870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015989101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional