Healthcare Provider Details

I. General information

NPI: 1255253324
Provider Name (Legal Business Name): ISAAC VIEYRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 LAKESIDE DR
BANNOCKBURN IL
60015-1265
US

IV. Provider business mailing address

2215 LAKESIDE DR
BANNOCKBURN IL
60015-1265
US

V. Phone/Fax

Practice location:
  • Phone: 847-881-6001
  • Fax:
Mailing address:
  • Phone: 847-881-6001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149.032006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: