MEDICARE: BROOKE PETERSEN COUNSELING PLLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	180013512	OTHER	IL	LCPC

General Provider Information

NPI Number	:	1154905651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKE PETERSEN COUNSELING PLLC

Provider Business Mailing Address
First Line	:	547 S CLARK ST APT 1001
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-1547
Country	:	US
Telephone Number	:	630-803-1062
Fax Number	:

Provider Business Practice Location Address
First Line	:	3609 N MAGNOLIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3820
Country	:	US
Telephone Number	:	630-803-1062
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	BROOKE N PETERSEN
Credential	:	LCPC
Telephone Number	:	630-803-1062

Provider Enumeration Date	:	05/11/2021
Last Update Date	:	05/11/2021

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