Individual
MRS. OTHELLA BANNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCPC
Contact information
Practice address
641 W 63RD ST, CHICAGO, IL 60621-2032
(312) 747-7496
Mailing address
641 W 63RD ST, CHICAGO, IL 60621-2032
(312) 747-7496
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
101Y00000X
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
180001054
LICENSE
IL
Enumeration date
06/19/2013
Last updated
06/19/2013
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