MEDICARE: MS. THERESE M DONNERS 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	101Y00000X	Counselor		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001622780	OTHER	IL	BLUE CROSS NUMBER

General Provider Information

NPI Number	:	1346372315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THERESE M DONNERS LCPC

Provider Business Mailing Address
First Line	:	11415 S FAIRFIELD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-1906
Country	:	US
Telephone Number	:	773-445-9848
Fax Number	:

Provider Business Practice Location Address
First Line	:	10725 S WESTERN AVE
Second Line	:	SECOND FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60643-3135
Country	:	US
Telephone Number	:	773-445-9848
Fax Number	:

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

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	07/08/2007

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