MEDICARE: MR. KEVIN MCCLURE 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	180-006803	IL

General Provider Information

NPI Number	:	1457458754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN MCCLURE LCPC

Provider Business Mailing Address
First Line	:	5016 NORTH UNIVERSITY ST
Second Line	:	SUITE 101
City	:	PEORIA
State	:	IL
Zip	:	61614-4763
Country	:	US
Telephone Number	:	309-573-4834
Fax Number	:	312-254-1423

Provider Business Practice Location Address
First Line	:	5016 NORTH UNIVERSITY ST
Second Line	:	SUITE 101
City	:	PEORIA
State	:	IL
Zip	:	61614-4763
Country	:	US
Telephone Number	:	309-573-4834
Fax Number	:	312-254-1423

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	06/17/2014

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