Individual
ANITA JOHANSON MADDOX
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCPC
Contact information
Practice address
89 CEDAR AVE, LAKE VILLA, IL 60046-8411
(847) 265-7300
(847) 265-7301
Mailing address
PO BOX 764, LAKE VILLA, IL 60046-0764
(847) 265-7300
(847) 265-7301
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
180004644
IL
222Q00000X
Developmental Therapist
Primary
AM47190798P
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
04932271
BLUE SHIELD
IL
01
—
710957905
FEIN
IL
Enumeration date
02/08/2007
Last updated
09/21/2010
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