Healthcare Provider Details

I. General information

NPI: 1780648493
Provider Name (Legal Business Name): JOSE RODRIGO NINO M.A., LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7366 N LINCOLN AVE SUITE 406
LINCOLNWOOD IL
60712-1708
US

IV. Provider business mailing address

7366 N LINCOLN AVE SUITE 406
LINCOLNWOOD IL
60712-1708
US

V. Phone/Fax

Practice location:
  • Phone: 773-307-4767
  • Fax: 847-673-4721
Mailing address:
  • Phone: 773-307-4767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-005762
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: