Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 2461 | IL |
Y | 101YP2500X | Professional Counselor | 180004804 | IL |
NPI | 1013074913 |
---|---|
Provider Name | Ms. Mary Kathleen O'hara |
First Address | Oak Brook, IL 60523-1234 |
Second Address | Oak Brook, IL 60523-1234 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2007 |
Last Update Date | 15/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02232178 | BLUE CROSS BLUE SHIELD (01) | IL |