Provider Demographics
NPI:1124480595
Name:SAN ROMAN, LUIS (LCPC)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
Last Name:SAN ROMAN
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 1:100 N WAUKEGAN RD STE 204
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-1660
Mailing Address - Country:US
Mailing Address - Phone:847-821-9346
Mailing Address - Fax:
Practice Address - Street 1:100 N WAUKEGAN RD STE 204
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-1660
Practice Address - Country:US
Practice Address - Phone:847-821-9346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178011862101YP2500X
IL18012203101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional