MEDICARE: KAREN JEAN KEWLEY 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	180007688	IL

General Provider Information

NPI Number	:	1356647721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN JEAN KEWLEY LCPC

Provider Business Mailing Address
First Line	:	710 BITTERSWEET AVE
Second Line	:
City	:	GERMANTOWN HILLS
State	:	IL
Zip	:	61548-8658
Country	:	US
Telephone Number	:	309-922-1145
Fax Number	:

Provider Business Practice Location Address
First Line	:	5016 N UNIVERSITY ST STE 109
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-4763
Country	:	US
Telephone Number	:	309-573-4834
Fax Number	:

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

Provider Enumeration Date	:	02/02/2011
Last Update Date	:	02/02/2011

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