MEDICARE: YOUR IDENTITY COUNSELING, PLLC

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

General Provider Information

NPI Number	:	1427767623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUR IDENTITY COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	119 S WESTERN AVE UNIT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-4644
Country	:	US
Telephone Number	:	773-234-4038
Fax Number	:	773-389-3599

Provider Business Practice Location Address
First Line	:	119 S WESTERN AVE UNIT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-4644
Country	:	US
Telephone Number	:	773-234-4038
Fax Number	:	773-389-3599

Authorized Official
Title or Position	:	OWNER
Name	:	AVERY M RAVITZ
Credential	:	LCPC
Telephone Number	:	773-873-2969

Provider Enumeration Date	:	11/16/2022
Last Update Date	:	12/17/2025

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