Provider Demographics
NPI:1528420155
Name:LAGACY, NATHAN PATRICK
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:PATRICK
Last Name:LAGACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 W. WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432
Mailing Address - Country:US
Mailing Address - Phone:815-722-4384
Mailing Address - Fax:815-722-4390
Practice Address - Street 1:3650 W. 183RD ST.
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430
Practice Address - Country:US
Practice Address - Phone:708-957-5042
Practice Address - Fax:708-206-2044
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180010099101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216521Medicare PIN