MEDICARE: JOSETTE WOLTHUSEN PSYD

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	103TC0700X	Clinical Psychologist	071-005997	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1633897	OTHER	IL	BCBS GRP NUMBER
2	320078	OTHER	IL	VALUE OPTIONS GRP NUMBER

General Provider Information

NPI Number	:	1235209214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSETTE WOLTHUSEN PSYD

Provider Business Mailing Address
First Line	:	3414A N KENNICOTT AVENUE
Second Line	:
City	:	ARLINGTON
State	:	IL
Zip	:	60004-5905
Country	:	US
Telephone Number	:	847-240-2211
Fax Number	:

Provider Business Practice Location Address
First Line	:	3413 N KENNICOTT AVE STE A
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-7815
Country	:	US
Telephone Number	:	847-240-2211
Fax Number	:

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/12/2011

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