Provider Demographics
NPI:1285260075
Name:MIRELES, RODOLFO (LCPC)
Entity type:Individual
Prefix:MR
First Name:RODOLFO
Middle Name:
Last Name:MIRELES
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 1:436 WRIGHT CT
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2058
Mailing Address - Country:US
Mailing Address - Phone:815-212-9376
Mailing Address - Fax:
Practice Address - Street 1:210 N HAMMES AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6680
Practice Address - Country:US
Practice Address - Phone:815-729-7790
Practice Address - Fax:815-725-8144
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012863101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional