Healthcare Provider Details

I. General information

NPI: 1679061873
Provider Name (Legal Business Name): BRIAN NOTTAGE MA, LPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W CHICAGO AVE
CHICAGO IL
60654-5106
US

IV. Provider business mailing address

130 S FAIRLANE AVE
ELMHURST IL
60126-3623
US

V. Phone/Fax

Practice location:
  • Phone: 312-943-6545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.009980
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: