MEDICARE: MR. BRYAN HEIDEL 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	101Y00000X	Counselor	180.011883	IL

General Provider Information

NPI Number	:	1639647696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYAN HEIDEL LCPC

Provider Business Mailing Address
First Line	:	1823 N SAINT LOUIS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4824
Country	:	US
Telephone Number	:	177-356-9955
Fax Number	:

Provider Business Practice Location Address
First Line	:	2950 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-4375
Country	:	US
Telephone Number	:	773-569-9553
Fax Number	:

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

Provider Enumeration Date	:	11/07/2018
Last Update Date	:	11/13/2018

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