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General NPI Number Information
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NPI Number | 1437374824
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Entity Type | Individual
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Provider Name | JOHN C SAMPLE LCPC
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Gender | Male
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Dates
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Enumeration Date | 04/13/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 23616 157TH AVE N
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City | CORDOVA
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State | IL
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Zip | 61242-9771
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Country | US
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Telephone | 309-654-2402
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Fax | 309-654-2885
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Provider Business Mailing Address
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Address Line | 17204 RIVER RD N
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City | CORDOVA
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State | IL
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Zip | 61242-9735
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Country | US
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Telephone | 309-654-2104
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Fax | 309-654-2885
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State | IL
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