Healthcare Provider Details

I. General information

NPI: 1912038910
Provider Name (Legal Business Name): RAYMOND C. WUNDERLICH JR. L.C.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 IL ROUTE 83 STE 204
LONG GROVE IL
60047-8034
US

IV. Provider business mailing address

318 W HALF DAY RD PMB 284
BUFFALO GROVE IL
60089-6547
US

V. Phone/Fax

Practice location:
  • Phone: 847-380-4806
  • Fax:
Mailing address:
  • Phone: 847-380-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-002811
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: