MEDICARE: DESPINA MCBRIDE MA, 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	180.007653	IL

General Provider Information

NPI Number	:	1164720215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESPINA MCBRIDE MA, LCPC

Provider Business Mailing Address
First Line	:	101 N VIRGINIA ST STE 115
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3446
Country	:	US
Telephone Number	:	815-790-3813
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 N VIRGINIA ST STE 115
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3446
Country	:	US
Telephone Number	:	815-790-3813
Fax Number	:

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

Provider Enumeration Date	:	03/14/2011
Last Update Date	:	03/14/2011

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