Provider Demographics
NPI:1265446652
Name:IDERAN, CHARLES MICHAEL (DMIN, LCPC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:IDERAN
Suffix:
Gender:M
Credentials:DMIN, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1061
Mailing Address - Country:US
Mailing Address - Phone:708-922-1194
Mailing Address - Fax:
Practice Address - Street 1:6006 W. 159TH ST
Practice Address - Street 2:BLDG. C
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452
Practice Address - Country:US
Practice Address - Phone:708-535-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health