Healthcare Provider Details

I. General information

NPI: 1205841954
Provider Name (Legal Business Name): COUNSELING CENTER OF THE NORTH SHORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

992 1/2 GREEN BAY RD
WINNETKA IL
60093
US

IV. Provider business mailing address

992 1/2 GREEN BAY RD
WINNETKA IL
60093-1722
US

V. Phone/Fax

Practice location:
  • Phone: 847-446-8060
  • Fax: 847-446-9768
Mailing address:
  • Phone: 847-446-8060
  • Fax: 847-446-9768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009790
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT M MARDIROSSIAN
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D., L.C.S.W.
Phone: 847-446-8060