Healthcare Provider Details

I. General information

NPI: 1689394611
Provider Name (Legal Business Name): JOHN JAMES KAPETAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MAIN ST STE 200
PARK RIDGE IL
60068-4044
US

IV. Provider business mailing address

7011 W TOUHY AVE APT 503
NILES IL
60714-4390
US

V. Phone/Fax

Practice location:
  • Phone: 847-668-4869
  • Fax:
Mailing address:
  • Phone: 847-668-4869
  • Fax: 847-728-5313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178008543
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: