Provider Demographics
NPI:1689981201
Name:COPRO CLINICAL CONCEPTS, PC
Entity Type:Organization
Organization Name:COPRO CLINICAL CONCEPTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:COSTA
Authorized Official - Middle Name:D
Authorized Official - Last Name:PROVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:847-529-8607
Mailing Address - Street 1:1755 E CARIB LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4003 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2110
Practice Address - Country:US
Practice Address - Phone:847-529-8607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty