=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265082523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS ANDREW KRYSZTOPIK LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2019
-----------------------------------------------------
Last Update Date | 11/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1457 N HALSTED ST UNIT B303
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-2677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-977-4737
-----------------------------------------------------
Fax | 708-974-2498
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10537 S ROBERTS RD
-----------------------------------------------------
City | PALOS HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60465-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-974-5100
-----------------------------------------------------
Fax | 708-974-2498
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 178.016826
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------