Basic Information
| Provider Information | |||||||||
| NPI: | 1376656884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEROLDT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA,LCPC,CADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEROLDT | ||||||||
| OtherFirstName: | THOMAS | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1001 ROHLWING RD | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475248800 | ||||||||
| FaxNumber: | 8475248824 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 SPRING HILL RING RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | WEST DUNDEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601187301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125133702 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 04/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180004128 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0081646690 | 01 | IL | BCBS | OTHER |