Provider Demographics
NPI:1770097396
Name:FOX, BERT (LCPC)
Entity type:Individual
Prefix:MR
First Name:BERT
Middle Name:
Last Name:FOX
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 1:5412 N CLARK ST STE 227
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1223
Mailing Address - Country:US
Mailing Address - Phone:773-673-9095
Mailing Address - Fax:
Practice Address - Street 1:5412 N CLARK ST STE 227
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1223
Practice Address - Country:US
Practice Address - Phone:773-673-9095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012648101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health