MEDICARE: MISS CLAY DEBRA CHALUPA 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

General Provider Information

NPI Number	:	1225121262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CLAY DEBRA CHALUPA LCPC

Provider Business Mailing Address
First Line	:	4085 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2117
Country	:	US
Telephone Number	:	773-883-9100
Fax Number	:	773-883-0005

Provider Business Practice Location Address
First Line	:	4085 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2117
Country	:	US
Telephone Number	:	773-883-9100
Fax Number	:	773-883-0005

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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