MEDICARE: MS. HEATHER SHANNON 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	180007881	IL
2	101YP2500X	Professional Counselor	178005052	IL

General Provider Information

NPI Number	:	1164721239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HEATHER SHANNON LCPC

Provider Business Mailing Address
First Line	:	1200 N ASHLAND AVE
Second Line	:	3RD FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60622-2259
Country	:	US
Telephone Number	:	773-850-2295
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 N ASHLAND AVE
Second Line	:	3RD FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60622-2259
Country	:	US
Telephone Number	:	773-850-2295
Fax Number	:

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

Provider Enumeration Date	:	03/15/2011
Last Update Date	:	06/17/2011

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