MEDICARE: OLESEA GORE LPC

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	178.021360	IL
2	101YP2500X	Professional Counselor	178.021360	IL

General Provider Information

NPI Number	:	1518765585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLESEA GORE LPC

Provider Business Mailing Address
First Line	:	44 N VIRGINIA ST STE 3B
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-4154
Country	:	US
Telephone Number	:	815-363-0864
Fax Number	:

Provider Business Practice Location Address
First Line	:	44 N VIRGINIA ST STE 3B
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-4154
Country	:	US
Telephone Number	:	815-363-0864
Fax Number	:

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

Provider Enumeration Date	:	03/05/2025
Last Update Date	:	07/14/2025

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