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General NPI Number Information
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NPI Number | 1720579238
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Entity Type | Individual
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Provider Name | BLAISE FAYOLLE
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Gender | Male
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Dates
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Enumeration Date | 05/21/2018
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Last Update Date | 05/21/2018
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Provider Practice Location Address
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Address Line | 455 N CITYFRONT PLAZA DR
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City | CHICAGO
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State | IL
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Zip | 60611-5503
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Country | US
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Telephone | 312-705-1503
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Fax |
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Provider Business Mailing Address
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Address Line | 1927 N HONORE ST APT 2B
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City | CHICAGO
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State | IL
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Zip | 60622-7560
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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 |
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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 | 178.013787
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License Number State | IL
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