Provider Demographics
NPI:1811584261
Name:IVY, CORLISS (LCPC)
Entity Type:Individual
Prefix:
First Name:CORLISS
Middle Name:
Last Name:IVY
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 1:206 CEDAR AVE UNIT 664
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-4629
Mailing Address - Country:US
Mailing Address - Phone:847-912-4991
Mailing Address - Fax:
Practice Address - Street 1:2520 ELISHA AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099
Practice Address - Country:US
Practice Address - Phone:224-707-0146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional