Healthcare Provider Details

I. General information

NPI: 1255940664
Provider Name (Legal Business Name): ROBERT BEACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2020
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2948 ARTESIAN RD STE 112
NAPERVILLE IL
60564-8559
US

IV. Provider business mailing address

3511 MALVINA CT
NAPERVILLE IL
60564-4159
US

V. Phone/Fax

Practice location:
  • Phone: 630-428-7890
  • Fax:
Mailing address:
  • Phone: 815-922-0013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.015970
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: