Provider Demographics
NPI:1144339714
Name:IDERAN, DAVID CHARLES (MHS, CADC, LCPC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CHARLES
Last Name:IDERAN
Suffix:
Gender:M
Credentials:MHS, CADC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 EASY ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-5128
Mailing Address - Country:US
Mailing Address - Phone:847-668-8969
Mailing Address - Fax:847-488-1401
Practice Address - Street 1:1532 WEATHERSTONE LN
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2019
Practice Address - Country:US
Practice Address - Phone:847-668-8969
Practice Address - Fax:847-488-1401
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional