Healthcare Provider Details

I. General information

NPI: 1801436100
Provider Name (Legal Business Name): DOUGLAS PAUL HINDERER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LATHROP AVE STE LL95
RIVER FOREST IL
60305-1875
US

IV. Provider business mailing address

15127 S 73RD AVE STE G
ORLAND PARK IL
60462-3425
US

V. Phone/Fax

Practice location:
  • Phone: 708-845-5500
  • Fax: 708-845-5505
Mailing address:
  • Phone: 708-845-5500
  • Fax: 708-845-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166001349
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: