Healthcare Provider Details

I. General information

NPI: 1356884134
Provider Name (Legal Business Name): CLINT ZAVAKOS MA LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N MICHIGAN AVE STE 1008
CHICAGO IL
60601-5310
US

IV. Provider business mailing address

307 N MICHIGAN AVE STE 1008
CHICAGO IL
60601-5310
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-3121
  • Fax:
Mailing address:
  • Phone: 773-234-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180010641
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: