Provider Demographics
NPI:1821630799
Name:DIERKS, ANITA LOUISE (LCPC)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:LOUISE
Last Name:DIERKS
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 1:9241 S IL ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-1607
Mailing Address - Country:US
Mailing Address - Phone:630-346-6877
Mailing Address - Fax:
Practice Address - Street 1:9241 S IL ROUTE 31
Practice Address - Street 2:
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-1607
Practice Address - Country:US
Practice Address - Phone:630-346-6877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008143101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional