Provider Demographics
NPI:1790431880
Name:OLDENBURG, NATHANIEL (LCPC)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:OLDENBURG
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 1:1501 HARBORWAY DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523-1932
Mailing Address - Country:US
Mailing Address - Phone:708-870-8184
Mailing Address - Fax:
Practice Address - Street 1:7210 N VILLA LAKE DR STE C
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8290
Practice Address - Country:US
Practice Address - Phone:309-713-1485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-27
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180012347101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional