Healthcare Provider Details

I. General information

NPI: 1356484067
Provider Name (Legal Business Name): LARRY NASH MA LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE SUITE 1922
CHICAGO IL
60602-3402
US

IV. Provider business mailing address

350 W OAKDALE AVE APT 1314
CHICAGO IL
60657-5652
US

V. Phone/Fax

Practice location:
  • Phone: 312-635-1753
  • Fax:
Mailing address:
  • Phone: 312-635-1753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180008037
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180008037
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: