Healthcare Provider Details

I. General information

NPI: 1427407279
Provider Name (Legal Business Name): JAMES PHELAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2016
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10735 S CICERO AVE SUITE 208
OAK LAWN IL
60453-5400
US

IV. Provider business mailing address

4608 W. 99TH ST.
OAK LAWN IL
60453
US

V. Phone/Fax

Practice location:
  • Phone: 708-424-0001
  • Fax:
Mailing address:
  • Phone: 773-573-3206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.011975
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180011498
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: