MEDICARE: ANDREA DAWN KAISER 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	22751	IL
2	101YP2500X	Professional Counselor	180005739	IL

General Provider Information

NPI Number	:	1053644849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA DAWN KAISER LCPC

Provider Business Mailing Address
First Line	:	1021 N MULFORD RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-3877
Country	:	US
Telephone Number	:	815-621-5945
Fax Number	:

Provider Business Practice Location Address
First Line	:	1021 N MULFORD RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-3877
Country	:	US
Telephone Number	:	815-621-5945
Fax Number	:

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

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	01/27/2016

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