Provider Demographics
NPI:1588635445
Name:IACUBINO, ANTHONY J (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:IACUBINO
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 WESTERN AVE.,
Mailing Address - Street 2:#301
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045
Mailing Address - Country:US
Mailing Address - Phone:847-668-5681
Mailing Address - Fax:
Practice Address - Street 1:1866 SHERIDAN RD.,
Practice Address - Street 2:#211
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035
Practice Address - Country:US
Practice Address - Phone:847-780-0055
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health