Provider Demographics
NPI:1447872296
Name:CHANG, ANNIE (MA, LPC)
Entity type:Individual
Prefix:MS
First Name:ANNIE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 W WABANSIA AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1337
Mailing Address - Country:US
Mailing Address - Phone:310-387-0451
Mailing Address - Fax:
Practice Address - Street 1:2630 W FLETCHER ST # 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-7110
Practice Address - Country:US
Practice Address - Phone:847-651-8643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015930101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional