Provider Demographics
NPI:1770275885
Name:MCCONICO, PATIENCE A
Entity type:Individual
Prefix:
First Name:PATIENCE
Middle Name:A
Last Name:MCCONICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 GREYSTEM CIR APT 301
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9335
Mailing Address - Country:US
Mailing Address - Phone:224-627-9740
Mailing Address - Fax:
Practice Address - Street 1:175 E HAWTHORN PKWY STE 235175
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1463
Practice Address - Country:US
Practice Address - Phone:630-428-7890
Practice Address - Fax:877-428-7891
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178018942101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health