MEDICARE: VICTORIA L NYBERG LPC

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	178.007157	IL

General Provider Information

NPI Number	:	1316297443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA L NYBERG LPC

Provider Business Mailing Address
First Line	:	5250 N PAULINA ST UNIT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-2030
Country	:	US
Telephone Number	:	650-283-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	5301 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-2113
Country	:	US
Telephone Number	:	773-234-4833
Fax Number	:

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

Provider Enumeration Date	:	09/17/2012
Last Update Date	:	09/17/2012

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