=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407265143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATIVE HEALTH COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2014
-----------------------------------------------------
Last Update Date | 11/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4305 N LINCOLN AVE SUITE M
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-687-0108
-----------------------------------------------------
Fax | 312-380-0317
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4305 N LINCOLN AVE SUITE M
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-687-0108
-----------------------------------------------------
Fax | 312-380-0317
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MR. HECTOR ANTONIO HERNANDEZ
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 847-687-0108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------