Healthcare Provider Details

I. General information

NPI: 1528134277
Provider Name (Legal Business Name): NORTHSIDE COUNSELING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20130 SAMARA TRL
LAKE ANN MI
49650-9685
US

IV. Provider business mailing address

20130 SAMARA TRL
LAKE ANN MI
49650-9685
US

V. Phone/Fax

Practice location:
  • Phone: 773-960-8359
  • Fax:
Mailing address:
  • Phone: 773-960-8359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180000932
License Number StateIL

VIII. Authorized Official

Name: SUSAN THOMPSON
Title or Position: PRESIDENT
Credential: LCPC, LPC
Phone: 773-960-8359