Provider Demographics
NPI:1942553623
Name:MVICKMANLTD
Entity Type:Organization
Organization Name:MVICKMANLTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, CADC
Authorized Official - Phone:847-660-3747
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:847-660-3747
Mailing Address - Fax:
Practice Address - Street 1:200 W SUPERIOR ST
Practice Address - Street 2:SUITE 403
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-3553
Practice Address - Country:US
Practice Address - Phone:847-660-3747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty