Healthcare Provider Details

I. General information

NPI: 1063659423
Provider Name (Legal Business Name): SAMARITAN COUNSELING CENTER OF THE NORTHWEST SUBURBS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HART RD SUITE 250
BARRINGTON IL
60010-2671
US

IV. Provider business mailing address

800 HART RD SUITE 250
BARRINGTON IL
60010-2671
US

V. Phone/Fax

Practice location:
  • Phone: 847-382-4673
  • Fax:
Mailing address:
  • Phone: 847-382-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. LORA J WIENS
Title or Position: LICENSED CLINICAL PROFESSIONAL COUN
Credential: PSY.D
Phone: 847-382-4673