Provider Demographics
NPI:1790141232
Name:COPERTINO, MARK (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:COPERTINO
Suffix:
Gender:M
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 CRESCENT BLVD
Mailing Address - Street 2:SUITE 229
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4176
Mailing Address - Country:US
Mailing Address - Phone:630-440-9013
Mailing Address - Fax:
Practice Address - Street 1:526 CRESCENT BLVD
Practice Address - Street 2:SUITE 229
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4176
Practice Address - Country:US
Practice Address - Phone:630-440-9013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009951101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional