MEDICARE: MS. CRYSTAL PACE 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	180.012112	IL

General Provider Information

NPI Number	:	1114796448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CRYSTAL PACE LCPC

Provider Business Mailing Address
First Line	:	300 E RANDOLPH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-5099
Country	:	US
Telephone Number	:	312-653-0021
Fax Number	:	312-309-0368

Provider Business Practice Location Address
First Line	:	300 E RANDOLPH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-5099
Country	:	US
Telephone Number	:	312-653-0021
Fax Number	:	312-309-0368

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

Provider Enumeration Date	:	12/28/2023
Last Update Date	:	12/28/2023

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