Healthcare Provider Details

I. General information

NPI: 1376656884
Provider Name (Legal Business Name): THOMAS HEROLDT MA,LCPC,CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: THOMAS HEROLDT

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 SPRING HILL RING RD STE 105
WEST DUNDEE IL
60118-7301
US

IV. Provider business mailing address

1001 ROHLWING RD
ELK GROVE VILLAGE IL
60007-3217
US

V. Phone/Fax

Practice location:
  • Phone: 312-513-3702
  • Fax:
Mailing address:
  • Phone: 847-524-8800
  • Fax: 847-524-8824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180004128
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: