Healthcare Provider Details

I. General information

NPI: 1275285108
Provider Name (Legal Business Name): PATRICK VICKERY CRC, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE # 116-C
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

820 S DAMEN AVE # 116-C
CHICAGO IL
60612-3728
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-5846
  • Fax: 312-569-5913
Mailing address:
  • Phone: 312-569-5846
  • Fax: 312-569-5913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number00344723
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: