MEDICARE: JOHN WANTY 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	180008461	IL

General Provider Information

NPI Number	:	1922343565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WANTY LCPC

Provider Business Mailing Address
First Line	:	410 S MICHIGAN AVE
Second Line	:	SUITE 525, STUDIO 524
City	:	CHICAGO
State	:	IL
Zip	:	60605-1308
Country	:	US
Telephone Number	:	773-492-1476
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 S MICHIGAN AVE
Second Line	:	SUITE 525, STUDIO 524
City	:	CHICAGO
State	:	IL
Zip	:	60605-1308
Country	:	US
Telephone Number	:	773-492-1476
Fax Number	:

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

Provider Enumeration Date	:	12/09/2012
Last Update Date	:	12/11/2013

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