Provider Demographics
NPI:1093156127
Name:EHRETSMAN, LARRY (LCPC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:EHRETSMAN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12825 E TANGLEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1619
Mailing Address - Country:US
Mailing Address - Phone:708-436-9534
Mailing Address - Fax:
Practice Address - Street 1:17255 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3401
Practice Address - Country:US
Practice Address - Phone:708-633-4533
Practice Address - Fax:708-633-4531
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.003642101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.003642OtherLICENSED CLINICAL PROFESSIONAL COUNSELOR
IL180.003642OtherSTATE OF ILLINOIS