MEDICARE: KELSEY M DAGENAIS 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	180010357	IL

General Provider Information

NPI Number	:	1457701070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY M DAGENAIS LCPC

Provider Business Mailing Address
First Line	:	5912 EL MORRO LN
Second Line	:
City	:	OAK FOREST
State	:	IL
Zip	:	60452-1922
Country	:	US
Telephone Number	:	708-560-3069
Fax Number	:

Provider Business Practice Location Address
First Line	:	5912 EL MORRO LN
Second Line	:
City	:	OAK FOREST
State	:	IL
Zip	:	60452-1922
Country	:	US
Telephone Number	:	708-560-3069
Fax Number	:

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

Provider Enumeration Date	:	06/14/2016
Last Update Date	:	02/19/2019

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