Healthcare Provider Details

I. General information

NPI: 1265446652
Provider Name (Legal Business Name): CHARLES MICHAEL IDERAN D.MIN., LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6006 W. 159TH ST BLDG. C
OAK FOREST IL
60452
US

IV. Provider business mailing address

1404 BRASSIE AVE
FLOSSMOOR IL
60422-1814
US

V. Phone/Fax

Practice location:
  • Phone: 708-535-7320
  • Fax:
Mailing address:
  • Phone: 708-922-1194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC 180-001087
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180001087
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: