MEDICARE: THERESA MARIE KOPITZKE 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	101Y00000X	Counselor
2	101YP2500X	Professional Counselor	180017559	IL

General Provider Information

NPI Number	:	1053280610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA MARIE KOPITZKE LCPC

Provider Business Mailing Address
First Line	:	2650 RIDGE AVE
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 CENTRAL ST STE 640
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-1780
Country	:	US
Telephone Number	:	847-869-0520
Fax Number	:

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

Provider Enumeration Date	:	11/03/2025
Last Update Date	:	02/03/2026

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