Healthcare Provider Details

I. General information

NPI: 1174989552
Provider Name (Legal Business Name): COPERTINO COUNSELING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 CRESCENT BLVD
GLEN ELLYN IL
60137-4176
US

IV. Provider business mailing address

526 CRESCENT BLVD
GLEN ELLYN IL
60137-4176
US

V. Phone/Fax

Practice location:
  • Phone: 630-440-9013
  • Fax:
Mailing address:
  • Phone: 630-440-9013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number180.009951
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number180.009951
License Number StateIL

VIII. Authorized Official

Name: MARK COPERTINO
Title or Position: CLINICAL PROFESSIONAL COUNSELOR
Credential: MS, LCPC
Phone: 630-440-9013