Healthcare Provider Details

I. General information

NPI: 1801340302
Provider Name (Legal Business Name): ANDRE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9624 S CICERO AVE # 234
OAK LAWN IL
60453-3138
US

IV. Provider business mailing address

9624 S CICERO AVE
OAK LAWN IL
60453-3138
US

V. Phone/Fax

Practice location:
  • Phone: 773-307-8441
  • Fax:
Mailing address:
  • Phone: 773-307-8441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number149.018574
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: