Provider Demographics
NPI:1942352091
Name:MARDIS, MARGARET (MS LCPC)
Entity Type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:
Last Name:MARDIS
Suffix:
Gender:F
Credentials:MS LCPC
Other - Prefix:MS
Other - First Name:MAGGIE
Other - Middle Name:
Other - Last Name:MARDIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS LCPC
Mailing Address - Street 1:1000 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-4965
Mailing Address - Country:US
Mailing Address - Phone:630-515-1339
Mailing Address - Fax:630-515-1339
Practice Address - Street 1:1000 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-4965
Practice Address - Country:US
Practice Address - Phone:630-515-1339
Practice Address - Fax:630-515-1339
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01622943OtherBLUE CROSS BLUE SHIELD ID