Healthcare Provider Details

I. General information

NPI: 1194083253
Provider Name (Legal Business Name): PHILLIP CROTEAU-CHONKA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10537 S ROBERTS RD
PALOS HILLS IL
60465-1933
US

IV. Provider business mailing address

10537 S ROBERTS RD
PALOS HILLS IL
60465-1933
US

V. Phone/Fax

Practice location:
  • Phone: 708-974-5106
  • Fax: 708-974-2498
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180004099
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: