MEDICARE: MARGARET ANNE WEATHERLY 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		IL

General Provider Information

NPI Number	:	1437280575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARGARET ANNE WEATHERLY LCPC

Provider Business Mailing Address
First Line	:	12 TIMBER VIEW DR
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-7801
Country	:	US
Telephone Number	:	309-827-8905
Fax Number	:

Provider Business Practice Location Address
First Line	:	1505 EASTLAND DR STE LL1000
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-7905
Country	:	US
Telephone Number	:	309-663-1623
Fax Number	:

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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