Provider Demographics
NPI:1437374824
Name:SAMPLE, JOHN C (LCPC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:SAMPLE
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 1:17204 RIVER RD N
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:IL
Mailing Address - Zip Code:61242-9735
Mailing Address - Country:US
Mailing Address - Phone:309-654-2104
Mailing Address - Fax:309-654-2885
Practice Address - Street 1:23616 157TH AVE N
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:IL
Practice Address - Zip Code:61242-9771
Practice Address - Country:US
Practice Address - Phone:309-654-2402
Practice Address - Fax:309-654-2885
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional