Provider Demographics
NPI:1508204066
Name:MIYAMOTO, CHARLES S (REV; LPC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:MIYAMOTO
Suffix:
Gender:M
Credentials:REV; LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4726
Mailing Address - Country:US
Mailing Address - Phone:847-864-9133
Mailing Address - Fax:
Practice Address - Street 1:1427 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4726
Practice Address - Country:US
Practice Address - Phone:847-864-9133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008311101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional