Provider Demographics
NPI:1407112576
Name:ABC COUNSELING PC
Entity Type:Organization
Organization Name:ABC COUNSELING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:847-587-2222
Mailing Address - Street 1:25283 W TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7372
Mailing Address - Country:US
Mailing Address - Phone:847-587-2222
Mailing Address - Fax:847-587-7656
Practice Address - Street 1:25283 W TIMBER LN
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-7372
Practice Address - Country:US
Practice Address - Phone:847-587-2222
Practice Address - Fax:847-587-7656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-0062081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
149-001264OtherLCSW
0660-006208OtherPRO. SERVICE CORP LIC. #
049-001264OtherBLUE SHIELD PROVIDER #
L 2080-032716OtherTRICARE/CHAMPUS
149-001264OtherLCSW