Healthcare Provider Details

I. General information

NPI: 1205744273
Provider Name (Legal Business Name): RYNE AUSTIN THACKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3166 N LINCOLN AVE STE 200
CHICAGO IL
60657-3119
US

IV. Provider business mailing address

3218 N CLARK ST APT 604A
CHICAGO IL
60657-6664
US

V. Phone/Fax

Practice location:
  • Phone: 847-920-8811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.033190
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: