Healthcare Provider Details

I. General information

NPI: 1699563262
Provider Name (Legal Business Name): SAMUEL CROCKETT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 N SANGAMON ST
CHICAGO IL
60607-2202
US

IV. Provider business mailing address

932 W WASHINGTON BLVD
CHICAGO IL
60607-2217
US

V. Phone/Fax

Practice location:
  • Phone: 312-226-7984
  • Fax: 312-980-0482
Mailing address:
  • Phone: 312-226-7984
  • Fax: 312-980-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178-021245
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: