Provider Demographics
NPI:1902312895
Name:TAMURA, MIE (LCPC)
Entity Type:Individual
Prefix:
First Name:MIE
Middle Name:
Last Name:TAMURA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MIE
Other - Middle Name:
Other - Last Name:TAMURA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2110 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1954
Mailing Address - Country:US
Mailing Address - Phone:774-501-8699
Mailing Address - Fax:
Practice Address - Street 1:2110 WARREN ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1954
Practice Address - Country:US
Practice Address - Phone:774-501-8699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007566101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health