Healthcare Provider Details

I. General information

NPI: 1891881843
Provider Name (Legal Business Name): ANDRES ACOSTA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1644 W COLONIAL PKWY
INVERNESS IL
60067-1207
US

IV. Provider business mailing address

1644 W COLONIAL PKWY
INVERNESS IL
60067-1207
US

V. Phone/Fax

Practice location:
  • Phone: 847-776-4500
  • Fax: 847-776-4724
Mailing address:
  • Phone: 847-776-4500
  • Fax: 847-776-4724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149007194
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: