MEDICARE: LYNN RYDE MOOSMAN L.C.P.C.

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		IL

General Provider Information

NPI Number	:	1215052774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNN RYDE MOOSMAN L.C.P.C.

Provider Business Mailing Address
First Line	:	1212 CRANE BLVD
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-3014
Country	:	US
Telephone Number	:	847-977-8235
Fax Number	:

Provider Business Practice Location Address
First Line	:	1585 N MILWAUKEE AVE
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-1359
Country	:	US
Telephone Number	:	847-977-8235
Fax Number	:

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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