Healthcare Provider Details

I. General information

NPI: 1912397316
Provider Name (Legal Business Name): BRIAN TRUNCALE SR. LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4009 N BROADWAY ST
CHICAGO IL
60613-2110
US

IV. Provider business mailing address

1338 W ARGYLE ST 1N
CHICAGO IL
60640-3564
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-2586
  • Fax:
Mailing address:
  • Phone: 773-240-9910
  • Fax: 773-243-0058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180006450
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: