Provider Demographics
NPI:1639410467
Name:PARKS, RANDY S (MA LCPC)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:S
Last Name:PARKS
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 1:990 GROVE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-6514
Mailing Address - Country:US
Mailing Address - Phone:847-828-4826
Mailing Address - Fax:
Practice Address - Street 1:990 GROVE ST STE 510
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-6514
Practice Address - Country:US
Practice Address - Phone:847-828-4826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003761101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health