Doctor Name: | CHARLES MICHAEL IDERAN |
NPI Number: | 1265446652 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | D.MIN., LCPC |
License Number: | |
Business Practice Address: | 6006 W. 159th St Bldg. C Oak Forest, IL - 60452 |
Business Phone Number: | 7085357320 |
Business Fax Number: | |
Mailing Address: | 923 Maple Rd, FLOSSMOOR |
State: | IL |
Postal Code: | 604221061 |
Phone Number: | 7089221194 |
Fax Number: | |
NPI Enumeration Date: | 07/28/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |