MEDICARE: MS. GRAZYNA WISNIOWSKA L.C.P.C.,C.A.D.C.

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01635112	OTHER	IL	BC/BS

General Provider Information

NPI Number	:	1760654669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GRAZYNA WISNIOWSKA L.C.P.C.,C.A.D.C.

Provider Business Mailing Address
First Line	:	930 MAPLETON AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-1404
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5420 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1225
Country	:	US
Telephone Number	:	708-250-2468
Fax Number	:

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

Provider Enumeration Date	:	03/31/2008
Last Update Date	:	03/31/2008

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