Provider Demographics
NPI:1679906556
Name:VELASCO, IVAN (LCPC)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:VELASCO
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 OLD ORCHARD RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1027
Mailing Address - Country:US
Mailing Address - Phone:847-260-8164
Mailing Address - Fax:847-728-8675
Practice Address - Street 1:5225 OLD ORCHARD RD
Practice Address - Street 2:SUITE 5
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1027
Practice Address - Country:US
Practice Address - Phone:847-260-8164
Practice Address - Fax:847-728-8675
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008757101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health