Provider Demographics
NPI:1366657587
Name:WEISS, MICHAEL A (LCPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:WEISS
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 1:2738 W FARGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1316
Mailing Address - Country:US
Mailing Address - Phone:773-764-8893
Mailing Address - Fax:
Practice Address - Street 1:2738 W FARGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-1316
Practice Address - Country:US
Practice Address - Phone:773-764-8893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001623064OtherBLUE CROSS PROVIDER