MEDICARE: SUSAN MARIE WORTMAN 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	101YP2500X	Professional Counselor	180.010657	IL

General Provider Information

NPI Number	:	1124513239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MARIE WORTMAN LCPC

Provider Business Mailing Address
First Line	:	2603 W CORTLAND ST # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4210
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 N MICHIGAN AVE STE 202
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-7940
Country	:	US
Telephone Number	:	312-278-3054
Fax Number	:

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

Provider Enumeration Date	:	06/30/2018
Last Update Date	:	06/30/2018

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