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General NPI Number Information
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NPI Number | 1689981201
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Entity Type | Organization
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Legal Business Name | COPRO CLINICAL CONCEPTS, PC
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Dates
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Enumeration Date | 09/02/2010
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Last Update Date | 09/02/2010
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Provider Practice Location Address
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Address Line | 4003 N BROADWAY ST
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City | CHICAGO
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State | IL
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Zip | 60613-2110
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Country | US
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Telephone | 847-529-8607
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Fax |
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Provider Business Mailing Address
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Address Line | 1755 E CARIB LN
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City | MOUNT PROSPECT
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State | IL
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Zip | 60056-1703
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. COSTA D. PROVIS
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Credential | L.C.P.C.
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Telephone | 847-529-8607
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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