MEDICARE: MARY C LOHSE L.C.S.W.

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DA330A	OTHER	FL	MEDICARE PTAN

General Provider Information

NPI Number	:	1619017456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY C LOHSE L.C.S.W.

Provider Business Mailing Address
First Line	:	4626 SW OTT CT
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6643
Country	:	US
Telephone Number	:	772-224-6610
Fax Number	:	772-237-4812

Provider Business Practice Location Address
First Line	:	4626 SW OTT CT
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6643
Country	:	US
Telephone Number	:	772-224-6610
Fax Number	:	772-237-4812

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

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	11/18/2010

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