Provider Demographics
NPI:1841736592
Name:WELTERS, EDNINA (LCPC)
Entity type:Individual
Prefix:
First Name:EDNINA
Middle Name:
Last Name:WELTERS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3976 N AVONDALE AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2900
Mailing Address - Country:US
Mailing Address - Phone:253-254-6882
Mailing Address - Fax:
Practice Address - Street 1:3976 N AVONDALE AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2900
Practice Address - Country:US
Practice Address - Phone:253-254-6882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007504101YM0800X
IL180.007504101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180007504Medicaid