Provider Demographics
NPI:1457545394
Name:MANCINO, MAXINE ANN (LCPC)
Entity Type:Individual
Prefix:MS
First Name:MAXINE
Middle Name:ANN
Last Name:MANCINO
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18161 MORRIS AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2108
Mailing Address - Country:US
Mailing Address - Phone:708-798-5706
Mailing Address - Fax:
Practice Address - Street 1:18161 MORRIS AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2108
Practice Address - Country:US
Practice Address - Phone:708-798-5706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional