Healthcare Provider Details

I. General information

NPI: 1285353060
Provider Name (Legal Business Name): PAUL BROUWER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

IV. Provider business mailing address

1430 N DEARBORN ST APT 206
CHICAGO IL
60610-5543
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-0205
  • Fax:
Mailing address:
  • Phone: 616-558-7454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178018258
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: