Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003283409 |
---|---|
Provider Name | Mr. Raymond Bernard Mcqueen |
First Address | Waukegan, IL 60085-2321 |
Second Address | Waukegan, IL 60085-2321 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2015 |
Last Update Date | 23/09/2015 |