Provider Demographics
NPI:1306440094
Name:PAGE, BRYONY AGATHA (LPC)
Entity type:Individual
Prefix:MISS
First Name:BRYONY
Middle Name:AGATHA
Last Name:PAGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6131 N WINTHROP AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2607
Mailing Address - Country:US
Mailing Address - Phone:860-964-0526
Mailing Address - Fax:
Practice Address - Street 1:3448 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-9740
Practice Address - Country:US
Practice Address - Phone:773-245-3725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015407101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health