Provider Demographics
NPI:1972792604
Name:BURT, CHARLES R (LCPC)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:R
Last Name:BURT
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 1:3319 N SHEFFIELD AVE UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2293
Mailing Address - Country:US
Mailing Address - Phone:773-429-9454
Mailing Address - Fax:
Practice Address - Street 1:3319 N SHEFFIELD AVE UNIT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2293
Practice Address - Country:US
Practice Address - Phone:773-429-9454
Practice Address - Fax:866-897-4573
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007553101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional