MEDICARE: MR. GREGORY JOHN DEZULSKIS 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	180000725	IL

General Provider Information

NPI Number	:	1861720914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY JOHN DEZULSKIS LCPC

Provider Business Mailing Address
First Line	:	1340 S DAMEN AVE STE 205
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1170
Country	:	US
Telephone Number	:	312-738-5955
Fax Number	:	312-666-6978

Provider Business Practice Location Address
First Line	:	1340 S DAMEN AVE STE 205
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-1170
Country	:	US
Telephone Number	:	312-738-5955
Fax Number	:	312-666-6978

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

Provider Enumeration Date	:	12/01/2009
Last Update Date	:	12/01/2009

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