MEDICARE: MRS. ANGELA MARVEL 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	180001060	IL

General Provider Information

NPI Number	:	1295945061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGELA MARVEL LCPC

Provider Business Mailing Address
First Line	:	2413 GLENCOE ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-6588
Country	:	US
Telephone Number	:	217-415-4052
Fax Number	:

Provider Business Practice Location Address
First Line	:	2413 GLENCOE ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-6588
Country	:	US
Telephone Number	:	217-415-4052
Fax Number	:

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/13/2013

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