Provider Demographics
NPI:1649493941
Name:LICATA, PHILLIP MARK (LCPC)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:MARK
Last Name:LICATA
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 1:18557 W COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2219
Mailing Address - Country:US
Mailing Address - Phone:847-231-4056
Mailing Address - Fax:
Practice Address - Street 1:1000 JORIE BLVD
Practice Address - Street 2:SUITE 48
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2214
Practice Address - Country:US
Practice Address - Phone:847-951-0338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004784101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional