Provider Demographics
NPI:1982045175
Name:SAN PEDRO-KOONTZ, EVA (LPC)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:SAN PEDRO-KOONTZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 N CLARENDON AVE
Mailing Address - Street 2:#2110
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2698
Mailing Address - Country:US
Mailing Address - Phone:773-622-6218
Mailing Address - Fax:773-622-7440
Practice Address - Street 1:6250 W NORTH AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-3861
Practice Address - Country:US
Practice Address - Phone:773-622-6218
Practice Address - Fax:773-622-7440
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.004410101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional