=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932970324
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID RAYMOND LAURICH LCPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2024
-----------------------------------------------------
Last Update Date | 01/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 EISENHOWER LN STE 900
-----------------------------------------------------
City | LISLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60532-2135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-428-7890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16723 S SUNSET RIDGE CT
-----------------------------------------------------
City | LOCKPORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60441-7677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-474-6657
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 180.015537
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------