=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992849871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS A CLELAND LCPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5301 DEMPSTER ST 310
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-1846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-771-1196
-----------------------------------------------------
Fax | 773-725-1996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5762 N KINGSDALE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-6623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-725-1996
-----------------------------------------------------
Fax | 773-725-1996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------