Healthcare Provider Details

I. General information

NPI: 1649447939
Provider Name (Legal Business Name): MICHAEL HEARD LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHAEL HEARD M.A.

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MAIN ST STE 210
ANTIOCH IL
60002-1578
US

IV. Provider business mailing address

925 KILLARNEY DR
DYER IN
46311-1292
US

V. Phone/Fax

Practice location:
  • Phone: 847-903-5604
  • Fax:
Mailing address:
  • Phone: 773-618-2231
  • Fax: 219-865-7879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149006014
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149006014
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: