Provider Demographics
NPI:1972713022
Name:MAYWORM, CHRISTINE (DTH, PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MAYWORM
Suffix:
Gender:F
Credentials:DTH, PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BLUEBERRY RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2167
Mailing Address - Country:US
Mailing Address - Phone:847-816-0013
Mailing Address - Fax:847-680-3311
Practice Address - Street 1:150 BLUEBERRY RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2167
Practice Address - Country:US
Practice Address - Phone:847-816-0013
Practice Address - Fax:847-680-3311
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILCM08170993P222Q00000X
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCM08170993POtherEARLY INTERVENTION NUMBER