MEDICARE: MR. JOSHUA SMITH HETHERINGTON MSMFT

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	180-003937	IL
2	106H00000X	Marriage & Family Therapist	166-000557	IL

General Provider Information

NPI Number	:	1114053766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSHUA SMITH HETHERINGTON MSMFT

Provider Business Mailing Address
First Line	:	1138 W NORTH SHORE AVE
Second Line	:	APT 1S
City	:	CHICAGO
State	:	IL
Zip	:	60626-4664
Country	:	US
Telephone Number	:	773-791-0469
Fax Number	:

Provider Business Practice Location Address
First Line	:	1770 W BERTEAU AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1849
Country	:	US
Telephone Number	:	773-791-0469
Fax Number	:

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	04/26/2011

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