Provider Demographics
NPI:1780648493
Name:NINO, JOSE RODRIGO (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:RODRIGO
Last Name:NINO
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 1:7366 N LINCOLN AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1708
Mailing Address - Country:US
Mailing Address - Phone:773-307-4767
Mailing Address - Fax:
Practice Address - Street 1:7366 N LINCOLN AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1708
Practice Address - Country:US
Practice Address - Phone:773-307-4767
Practice Address - Fax:847-673-4721
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-005762101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL258267OtherCOMPSYCH PROVIDER NUMBER
IL01635496OtherBCBS PPO PROVIDER #