MEDICARE: JOANNA MARIE DY DE LEON MS, 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	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor	180014142	IL
3	101YP2500X	Professional Counselor	178014740	IL
4	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1194362947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANNA MARIE DY DE LEON MS, LCPC

Provider Business Mailing Address
First Line	:	4615 E STATE ST STE 204
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2158
Country	:	US
Telephone Number	:	815-708-9068
Fax Number	:

Provider Business Practice Location Address
First Line	:	4615 E STATE ST STE 204
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2158
Country	:	US
Telephone Number	:	815-708-9068
Fax Number	:	779-970-5908

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

Provider Enumeration Date	:	11/27/2019
Last Update Date	:	04/30/2024

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