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General NPI Number Information
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NPI Number | 1629513627
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Entity Type | Organization
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Legal Business Name | BREAKTHROUGHS LAKE COUNTY
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Dates
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Enumeration Date | 12/29/2016
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Last Update Date | 12/29/2016
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Provider Practice Location Address
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Address Line | 2402 DEERPATH DR
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City | LINDENHURST
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State | IL
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Zip | 60046-9074
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Country | US
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Telephone | 847-913-6212
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Fax |
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Provider Business Mailing Address
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Address Line | 2402 DEERPATH DR
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City | LINDENHURST
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State | IL
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Zip | 60046-9074
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Country | US
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Telephone | 847-913-6212
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JESSICA C GOSCHY
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Credential | LPC
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Telephone | 847-913-6212
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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 | 178.012232
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License Number State | IL
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