Healthcare Provider Details

I. General information

NPI: 1295419976
Provider Name (Legal Business Name): NATHAN KRETLOW MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 06/13/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N MICHIGAN AVE STE 1430
CHICAGO IL
60601-7653
US

IV. Provider business mailing address

5505 N CUMBERLAND AVE STE 307 ATTN 18205
CHICAGO IL
60656-4761
US

V. Phone/Fax

Practice location:
  • Phone: 312-766-6780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10386-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: