MEDICARE: HESHIMA MANCE 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	101Y00000X	Counselor	180015103	IL

General Provider Information

NPI Number	:	1184331845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HESHIMA MANCE LCPC

Provider Business Mailing Address
First Line	:	PO BOX 20
Second Line	:
City	:	LANSING
State	:	IL
Zip	:	60438-0020
Country	:	US
Telephone Number	:	312-525-1031
Fax Number	:

Provider Business Practice Location Address
First Line	:	4449 S LAKE PARK AVE UNIT 2S
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4189
Country	:	US
Telephone Number	:	312-525-1031
Fax Number	:

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

Provider Enumeration Date	:	11/02/2022
Last Update Date	:	05/15/2023

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