Provider Demographics
NPI:1548971179
Name:CHOLLAMPEL, TINA (MA, LPC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:CHOLLAMPEL
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SKOKIE BLVD STE 218
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-4043
Mailing Address - Country:US
Mailing Address - Phone:847-668-4295
Mailing Address - Fax:847-668-4295
Practice Address - Street 1:1400 RENAISSANCE DR STE 405
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1329
Practice Address - Country:US
Practice Address - Phone:847-668-4295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016978101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional