Healthcare Provider Details

I. General information

NPI: 1205269057
Provider Name (Legal Business Name): JOHN PETER MUCKIAN JR. LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13136 WESTERN AVE
BLUE ISLAND IL
60406-2423
US

IV. Provider business mailing address

13136 WESTERN AVE
BLUE ISLAND IL
60406-2423
US

V. Phone/Fax

Practice location:
  • Phone: 708-974-5800
  • Fax: 708-371-0466
Mailing address:
  • Phone: 708-974-5800
  • Fax: 708-371-0466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.002469
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: