Provider Demographics
NPI:1376899799
Name:WALL, ANDREW R (LCPC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:WALL
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 1:2302 W NORTH AVE
Mailing Address - Street 2:UNIT 1E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6260
Mailing Address - Country:US
Mailing Address - Phone:773-551-7204
Mailing Address - Fax:773-342-4200
Practice Address - Street 1:2302 W NORTH AVE
Practice Address - Street 2:UNIT 1E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-6260
Practice Address - Country:US
Practice Address - Phone:773-551-7204
Practice Address - Fax:773-342-4200
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008228101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health