Provider Demographics
NPI:1376656884
Name:HEROLDT, THOMAS (MA,LCPC,CADC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:HEROLDT
Suffix:
Gender:M
Credentials:MA,LCPC,CADC
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:HEROLDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1001 ROHLWING RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3217
Mailing Address - Country:US
Mailing Address - Phone:847-524-8800
Mailing Address - Fax:847-524-8824
Practice Address - Street 1:600 SPRING HILL RING RD STE 105
Practice Address - Street 2:
Practice Address - City:WEST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-7301
Practice Address - Country:US
Practice Address - Phone:312-513-3702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004128101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0081646690OtherBCBS