MEDICARE: SOFIA KHERAJ LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	180008962	IL

General Provider Information

NPI Number	:	1114386927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOFIA KHERAJ LCPC

Provider Business Mailing Address
First Line	:	803 N CAMPBELL AVE
Second Line	:	# 2C
City	:	CHICAGO
State	:	IL
Zip	:	60622-5457
Country	:	US
Telephone Number	:	214-223-6142
Fax Number	:

Provider Business Practice Location Address
First Line	:	803 N CAMPBELL AVE
Second Line	:	# 2C
City	:	CHICAGO
State	:	IL
Zip	:	60622-5457
Country	:	US
Telephone Number	:	214-223-6142
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2016
Last Update Date	:	02/22/2016

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