MEDICARE: JUDITH FUDALA 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	180002603	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0081646686	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1356454151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH FUDALA LCPC

Provider Business Mailing Address
First Line	:	916 CASS LN
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3046
Country	:	US
Telephone Number	:	847-494-6693
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 N ARLINGTON HEIGHTS RD
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-6075
Country	:	US
Telephone Number	:	847-463-1055
Fax Number	:

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

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	07/01/2016

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