1780192724 NPI number — KIMBERLY M ANTOS-HOGAN MA,LCPC, CRC,

Table of content: KIMBERLY M ANTOS-HOGAN MA,LCPC, CRC, (NPI 1780192724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780192724 NPI number — KIMBERLY M ANTOS-HOGAN MA,LCPC, CRC,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTOS-HOGAN
Provider First Name:
KIMBERLY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA,LCPC, CRC,
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780192724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21W675 DORCHESTER CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN ELLYN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60137-6411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-858-7030
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21W675 DORCHESTER CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ELLYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60137-6411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-740-8559
Provider Business Practice Location Address Fax Number:
630-740-8559
Provider Enumeration Date:
01/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  180000743 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15655 . This is a "BOARD CERTIFIED PROFESSIONAL COUNSELOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 00007720 . This is a "CERTIFIED REHABILITATION COUNSELOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 180000743 . This is a "COUNSELOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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