Healthcare Provider Details

I. General information

NPI: 1770919698
Provider Name (Legal Business Name): SEAN COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19150 S. KEDZIE AVE SUITE 201
FLOSSMOOR IL
60422
US

IV. Provider business mailing address

19150 S. KEDZIE AVE SUITE 201
FLOSSMOOR IL
60422
US

V. Phone/Fax

Practice location:
  • Phone: 708-300-8864
  • Fax:
Mailing address:
  • Phone: 708-300-8864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180014892
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180014892
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: