MEDICARE: MR. WILLIAM TIVA BOUNTHONG LCSW

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	101YM0800X	Mental Health Counselor	149025844	IL
2	1041C0700X	Clinical Social Worker	149025844	IL

General Provider Information

NPI Number	:	1144091505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM TIVA BOUNTHONG LCSW

Provider Business Mailing Address
First Line	:	7399 FOREST HILLS RD
Second Line	:
City	:	LOVES PARK
State	:	IL
Zip	:	61111-3974
Country	:	US
Telephone Number	:	815-708-7392
Fax Number	:	815-708-8248

Provider Business Practice Location Address
First Line	:	7399 FOREST HILLS RD
Second Line	:
City	:	LOVES PARK
State	:	IL
Zip	:	61111-3974
Country	:	US
Telephone Number	:	815-708-7392
Fax Number	:	815-708-8248

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

Provider Enumeration Date	:	01/12/2024
Last Update Date	:	02/22/2024

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