Provider Demographics
NPI:1821122797
Name:VICKMAN, MARCIA H (LCPC)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:H
Last Name:VICKMAN
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 1:3318 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1830
Mailing Address - Country:US
Mailing Address - Phone:847-682-8447
Mailing Address - Fax:
Practice Address - Street 1:2604 DEMPSTER ST
Practice Address - Street 2:SUITE 510
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-8412
Practice Address - Country:US
Practice Address - Phone:847-682-8447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.000505101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional