Healthcare Provider Details

I. General information

NPI: 1366032930
Provider Name (Legal Business Name): GEORGE WYNSLOW LIEBERT-HERETH LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1590 WEATHERSTONE LN UNIT SE
ELGIN IL
60123-2059
US

IV. Provider business mailing address

1135 E ALGONQUIN RD
DES PLAINES IL
60016-6305
US

V. Phone/Fax

Practice location:
  • Phone: 312-927-2373
  • Fax:
Mailing address:
  • Phone: 312-927-2373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.011960
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: