MEDICARE: MR. TYLER WURST 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	180008559	IL

General Provider Information

NPI Number	:	1356727390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER WURST LCPC

Provider Business Mailing Address
First Line	:	3939 N MOZART ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3619
Country	:	US
Telephone Number	:	773-574-9758
Fax Number	:

Provider Business Practice Location Address
First Line	:	3939 N MOZART ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3619
Country	:	US
Telephone Number	:	773-574-9758
Fax Number	:

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

Provider Enumeration Date	:	07/31/2015
Last Update Date	:	07/31/2015

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