Healthcare Provider Details

I. General information

NPI: 1659389047
Provider Name (Legal Business Name): DAVID JOSEPH KINZER M.A. LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 W PETERSON AVE SUITE 12
CHICAGO IL
60659-4108
US

IV. Provider business mailing address

1928 W WINONA ST 3
CHICAGO IL
60640-2609
US

V. Phone/Fax

Practice location:
  • Phone: 773-765-0604
  • Fax: 773-765-0622
Mailing address:
  • Phone: 773-765-0604
  • Fax: 773-765-0622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: