Provider Demographics
NPI:1639647696
Name:HEIDEL, BRYAN (LCPC)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:
Last Name:HEIDEL
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 1:1823 N SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4824
Mailing Address - Country:US
Mailing Address - Phone:177-356-9955
Mailing Address - Fax:
Practice Address - Street 1:2950 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4375
Practice Address - Country:US
Practice Address - Phone:773-569-9553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011883101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor