MEDICARE: TIARESSA N DOYLE 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	180.010643	IL

General Provider Information

NPI Number	:	1316243983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIARESSA N DOYLE LCPC

Provider Business Mailing Address
First Line	:	10620 BROOKS LN
Second Line	:	C2
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-1780
Country	:	US
Telephone Number	:	708-314-9923
Fax Number	:

Provider Business Practice Location Address
First Line	:	10620 BROOKS LN
Second Line	:	C2
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-1780
Country	:	US
Telephone Number	:	708-314-9923
Fax Number	:

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

Provider Enumeration Date	:	01/31/2011
Last Update Date	:	11/21/2016

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