MEDICARE: MR. ALBERT WOLFE LASER 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		IL

General Provider Information

NPI Number	:	1225234297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALBERT WOLFE LASER LCPC

Provider Business Mailing Address
First Line	:	5615 N BERNARD ST
Second Line	:	3RD FL
City	:	CHICAGO
State	:	IL
Zip	:	60659-3407
Country	:	US
Telephone Number	:	773-600-4205
Fax Number	:

Provider Business Practice Location Address
First Line	:	LYDIA HOME ASSOCIATION
Second Line	:	4300 W IRVING PARK RD
City	:	CHICAGO
State	:	IL
Zip	:	60641-2825
Country	:	US
Telephone Number	:	773-736-1447
Fax Number	:	773-736-6970

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

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	07/08/2007

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