Provider Demographics
NPI:1912139601
Name:VASTOLA, MARK (LCPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VASTOLA
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 1:2800 N SHERIDAN RD STE 110
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6162
Mailing Address - Country:US
Mailing Address - Phone:773-807-0841
Mailing Address - Fax:773-819-2995
Practice Address - Street 1:2800 N SHERIDAN RD STE 110
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6162
Practice Address - Country:US
Practice Address - Phone:773-807-0841
Practice Address - Fax:773-819-2995
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006765101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional