Healthcare Provider Details

I. General information

NPI: 1962860080
Provider Name (Legal Business Name): ANTON P GLEASON MA., NCC., LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6626 S KIMBARK AVE 2S
CHICAGO IL
60637-4488
US

IV. Provider business mailing address

6626 S KIMBARK AVE 2S
CHICAGO IL
60637-4488
US

V. Phone/Fax

Practice location:
  • Phone: 773-931-8379
  • Fax:
Mailing address:
  • Phone: 773-931-8379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009555
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: