MEDICARE: LAURA RENEE WRZESINSKI LMFT

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	106H00000X	Marriage & Family Therapist	T1159	OR
2	106H00000X	Marriage & Family Therapist	166.000996	IL
3	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1861755951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA RENEE WRZESINSKI LMFT

Provider Business Mailing Address
First Line	:	5131 N LINCOLN AVE STE 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2584
Country	:	US
Telephone Number	:	971-930-0089
Fax Number	:

Provider Business Practice Location Address
First Line	:	5131 N LINCOLN AVE STE 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2584
Country	:	US
Telephone Number	:	971-930-0089
Fax Number	:

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

Provider Enumeration Date	:	06/22/2012
Last Update Date	:	02/09/2022

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