Provider Demographics
NPI:1336362631
Name:BANGHART, MICHAEL ALAN
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALAN
Last Name:BANGHART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 S TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1626
Mailing Address - Country:US
Mailing Address - Phone:773-841-5150
Mailing Address - Fax:
Practice Address - Street 1:2501 W WASHINGTON BLVD STE 401
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2127
Practice Address - Country:US
Practice Address - Phone:773-645-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.002258101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor