Provider Demographics
NPI:1578826632
Name:CONN, DEREK ROBERT
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:ROBERT
Last Name:CONN
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 1:611 HARRIS DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1672
Mailing Address - Country:US
Mailing Address - Phone:847-275-3033
Mailing Address - Fax:
Practice Address - Street 1:5801 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6007
Practice Address - Country:US
Practice Address - Phone:312-744-1906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health