Basic Information
| Provider Information | |||||||||
| NPI: | 1750303129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GINTER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778000 | ||||||||
| FaxNumber: | 8475460083 | ||||||||
| Practice Location | |||||||||
| Address1: | 3012 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475460080 | ||||||||
| FaxNumber: | 8475460083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 08/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 180001882 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 180001882 | 05 | IL | MEDICAID |