=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558761700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRI BUKOFZER LCSW, CADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2014
-----------------------------------------------------
Last Update Date | 08/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 AMERICAN WAY
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60120-4341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-742-3545
-----------------------------------------------------
Fax | 847-742-3559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 278 HOBBLE BUSH LN
-----------------------------------------------------
City | VERNON HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60061-3145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-742-3545
-----------------------------------------------------
Fax | 847-697-3559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 149.016786
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------