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1265446652 NPI number — CHARLES MICHAEL IDERAN D.MIN., LCPC

NPI Number: 1265446652
Health Care Provider/Practitioner: CHARLES MICHAEL IDERAN D.MIN., LCPC

Information about “1265446652” NPI (CHARLES MICHAEL IDERAN D.MIN., LCPC) exists in 1265446652 in HTML format HTML  |  1265446652 in plain Text format TXT  |  1265446652 in PDF (Portable Document Format) PDF  |  1265446652 in an XML format XML  formats.

NPI Number : 1265446652 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1265446652",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "IDERAN",
    "FirstName": "CHARLES",
    "MiddleName": "MICHAEL",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "D.MIN., LCPC",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "1404 BRASSIE AVE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "FLOSSMOOR",
    "MailingAddressStateName": "IL",
    "MailingAddressPostalCode": "60422-1814",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "708-922-1194",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "6006 W. 159TH ST",
    "SecondLinePracticeLocationAddress": "BLDG. C",
    "PracticeLocationAddressCityName": "OAK FOREST",
    "PracticeLocationAddressStateName": "IL",
    "PracticeLocationAddressPostalCode": "60452",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "708-535-7320",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "07/28/2006",
    "LastUpdateDate": "12/04/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "101YP2500X",
          "TaxonomyName": "Professional Counselor",
          "LicenseNumber": "180001087",
          "LicenseNumberStateCode": "IL",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "101YM0800X",
          "TaxonomyName": "Mental Health Counselor",
          "LicenseNumber": "LCPC 180-001087",
          "LicenseNumberStateCode": "IL",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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