Provider Demographics
NPI:1386994804
Name:HARWELL, ERIC V (LCPC, QMHP)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:V
Last Name:HARWELL
Suffix:
Gender:M
Credentials:LCPC, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1814
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4814
Mailing Address - Country:US
Mailing Address - Phone:708-296-0214
Mailing Address - Fax:
Practice Address - Street 1:4137 SAUK TRL
Practice Address - Street 2:SUITE D
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1253
Practice Address - Country:US
Practice Address - Phone:708-296-0214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.004975101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health