Healthcare Provider Details

I. General information

NPI: 1376217828
Provider Name (Legal Business Name): RAYMOND JOHN MONGE JR. MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N MICHIGAN AVE STE 1400
CHICAGO IL
60601-4011
US

IV. Provider business mailing address

808 S MICHIGAN AVE APT 3807
CHICAGO IL
60605-2299
US

V. Phone/Fax

Practice location:
  • Phone: 312-815-9660
  • Fax:
Mailing address:
  • Phone: 216-856-4850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: