Healthcare Provider Details

I. General information

NPI: 1285260075
Provider Name (Legal Business Name): RODOLFO MIRELES LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N HAMMES AVE
JOLIET IL
60435-6680
US

IV. Provider business mailing address

436 WRIGHT CT
BOLINGBROOK IL
60440-2058
US

V. Phone/Fax

Practice location:
  • Phone: 815-729-7790
  • Fax: 815-725-8144
Mailing address:
  • Phone: 815-212-9376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.012863
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: