Provider Demographics
NPI:1649665993
Name:JOSEPH A RENGUSO
Entity type:Organization
Organization Name:JOSEPH A RENGUSO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:RENGUSO
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:847-506-3597
Mailing Address - Street 1:4160 ROUTE 83
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047
Mailing Address - Country:US
Mailing Address - Phone:847-506-3597
Mailing Address - Fax:
Practice Address - Street 1:4160 ROUTE 83
Practice Address - Street 2:SUITE 202
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-8034
Practice Address - Country:US
Practice Address - Phone:847-506-3597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty