Provider Demographics
NPI:1528667797
Name:MAGSOMBOL, RICH G
Entity type:Individual
Prefix:
First Name:RICH
Middle Name:G
Last Name:MAGSOMBOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4221 N PHEASANT TRAIL CT UNIT 6
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-7996
Mailing Address - Country:US
Mailing Address - Phone:847-924-4111
Mailing Address - Fax:
Practice Address - Street 1:1835 W CENTRAL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2410
Practice Address - Country:US
Practice Address - Phone:847-870-2636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.006727101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health