Provider Demographics
NPI:1760113005
Name:LICAVOLI, YVONNE
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:
Last Name:LICAVOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9626 RIDGE HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2319
Mailing Address - Country:US
Mailing Address - Phone:314-397-1428
Mailing Address - Fax:
Practice Address - Street 1:4509 N ILLINOIS ST STE 4
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1524
Practice Address - Country:US
Practice Address - Phone:314-669-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178015261101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional