Healthcare Provider Details

I. General information

NPI: 1023476769
Provider Name (Legal Business Name): NGOZI HARRIS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12510 VINCENNES RD UNIT 4
BLUE ISLAND IL
60406-1674
US

IV. Provider business mailing address

12510 VINCENNES RD UNIT 4
BLUE ISLAND IL
60406-1674
US

V. Phone/Fax

Practice location:
  • Phone: 708-691-9424
  • Fax:
Mailing address:
  • Phone: 708-691-9424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.009873
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: