Healthcare Provider Details

I. General information

NPI: 1811063621
Provider Name (Legal Business Name): ROGER MRAZEK LCPC,CADC,CEAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 W 112TH ST CHICAGO
CHICAGO IL
60655-1351
US

IV. Provider business mailing address

1335 S. PRAIRIE AVE. #1503 CHICAGO
CHICAGO IL
60605-3138
US

V. Phone/Fax

Practice location:
  • Phone: 773-879-8696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180000808
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: