MEDICARE: MISS QUEENA LOUISE HOWARD 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	180.007518	IL

General Provider Information

NPI Number	:	1275767717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS QUEENA LOUISE HOWARD LCPC

Provider Business Mailing Address
First Line	:	2111 N IDAHO ST
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61604-3054
Country	:	US
Telephone Number	:	309-363-1400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2111 N IDAHO ST
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61604-3054
Country	:	US
Telephone Number	:	309-363-1400
Fax Number	:

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

Provider Enumeration Date	:	05/12/2009
Last Update Date	:	10/19/2010

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