Provider Demographics
NPI:1811063621
Name:MRAZEK, ROGER (LCPC,CADC,CEAP)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:MRAZEK
Suffix:
Gender:M
Credentials:LCPC,CADC,CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 S. PRAIRIE AVE. #1503
Mailing Address - Street 2:CHICAGO
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2445 W 112TH ST
Practice Address - Street 2:CHICAGO
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-1351
Practice Address - Country:US
Practice Address - Phone:773-879-8696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180000808101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL000-163-6162OtherBLUE CROSS BLUE SHIELD