Healthcare Provider Details

I. General information

NPI: 1508706656
Provider Name (Legal Business Name): JOHNNIE J PURNELL CADC,CODP1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 111TH ST
CHICAGO IL
60628-4200
US

IV. Provider business mailing address

45 W 111TH ST
CHICAGO IL
60628-4200
US

V. Phone/Fax

Practice location:
  • Phone: 312-409-3981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCODP1-195012
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADC-45491
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: