MEDICARE: BRIGID MOIRE KELLY DAGENFIELD 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	180010908	IL
2	101YP2500X	Professional Counselor	178011182	IL

General Provider Information

NPI Number	:	1033616354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIGID MOIRE KELLY DAGENFIELD LCPC

Provider Business Mailing Address
First Line	:	5615 W GIDDINGS ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3213
Country	:	US
Telephone Number	:	614-580-7349
Fax Number	:

Provider Business Practice Location Address
First Line	:	5419 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3686
Country	:	US
Telephone Number	:	312-869-9899
Fax Number	:

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

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	08/29/2024

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