MEDICARE: MS. MARY IVORY MA 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	180-000564	IL

General Provider Information

NPI Number	:	1750996815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY IVORY MA LCPC

Provider Business Mailing Address
First Line	:	600 S DEARBORN ST APT 1211
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-1895
Country	:	US
Telephone Number	:	312-859-6654
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 S DEARBORN ST APT 1211
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-1895
Country	:	US
Telephone Number	:	312-859-6654
Fax Number	:

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

Provider Enumeration Date	:	09/14/2020
Last Update Date	:	09/14/2020

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