MEDICARE: CHRYSALIS COUNSELING GROUP

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	180.007553	IL

General Provider Information

NPI Number	:	1407149693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRYSALIS COUNSELING GROUP

Provider Business Mailing Address
First Line	:	3257 N SHEFFIELD AVE
Second Line	:	SUITE 108
City	:	CHICAGO
State	:	IL
Zip	:	60657-2270
Country	:	US
Telephone Number	:	773-570-0088
Fax Number	:	773-404-5095

Provider Business Practice Location Address
First Line	:	3257 N SHEFFIELD AVE
Second Line	:	SUITE 108
City	:	CHICAGO
State	:	IL
Zip	:	60657-2270
Country	:	US
Telephone Number	:	773-570-0088
Fax Number	:	773-404-5095

Authorized Official
Title or Position	:	PRINCIPLE
Name	:	CHARLES BURT
Credential	:	LCPC
Telephone Number	:	773-570-0088

Provider Enumeration Date	:	05/20/2011
Last Update Date	:	05/20/2011

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Directions to “CHRYSALIS COUNSELING GROUP ” Practice Location

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