Provider Demographics
NPI:1245842814
Name:ANDERSON, MICHAEL (LPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 N HUMBOLDT BLVD # 17
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3844
Mailing Address - Country:US
Mailing Address - Phone:773-398-5142
Mailing Address - Fax:
Practice Address - Street 1:3317 W 95TH ST STE 101
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2243
Practice Address - Country:US
Practice Address - Phone:708-529-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178015917101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional