Provider Demographics
NPI:1831650407
Name:KOROLCZUK, LOAN NGUYEN
Entity Type:Individual
Prefix:
First Name:LOAN
Middle Name:NGUYEN
Last Name:KOROLCZUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LOAN
Other - Middle Name:TUONG
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6066 STRATHMOOR DR # C2
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6633
Mailing Address - Country:US
Mailing Address - Phone:779-800-5881
Mailing Address - Fax:815-399-9306
Practice Address - Street 1:6066 STRATHMOOR DR # C2
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6633
Practice Address - Country:US
Practice Address - Phone:779-800-5881
Practice Address - Fax:815-399-9306
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IL178.014666101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional