Healthcare Provider Details

I. General information

NPI: 1427297787
Provider Name (Legal Business Name): FRANK CHARLES PONZIANO JR. A.A.S. C.A.D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2009
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 WAUKEGAN RD ST.100
NORTHFIELD IL
60093-2757
US

IV. Provider business mailing address

2235 N 75TH AVE APT G
ELMWOOD PARK IL
60707-2602
US

V. Phone/Fax

Practice location:
  • Phone: 847-446-2270
  • Fax: 847-446-2172
Mailing address:
  • Phone: 773-981-0620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number26662
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: