Healthcare Provider Details

I. General information

NPI: 1659125060
Provider Name (Legal Business Name): CRYSTAL ARIELLA BERNARD LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2071 N SOUTHPORT AVE STE 100
CHICAGO IL
60614-4015
US

IV. Provider business mailing address

1955 N SAINT LOUIS AVE APT 304
CHICAGO IL
60647-2049
US

V. Phone/Fax

Practice location:
  • Phone: 630-428-7890
  • Fax:
Mailing address:
  • Phone: 773-580-0787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.019946
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: