MEDICARE: FAYE FREEMAN-SMITH

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	180002594	IL

General Provider Information

NPI Number	:	1457728206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAYE FREEMAN-SMITH

Provider Business Mailing Address
First Line	:	9139 APOLLO RD
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61705-6886
Country	:	US
Telephone Number	:	309-530-7758
Fax Number	:

Provider Business Practice Location Address
First Line	:	2416 E WASHINGTON ST STE A2
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-1608
Country	:	US
Telephone Number	:	309-530-7758
Fax Number	:

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

Provider Enumeration Date	:	08/27/2015
Last Update Date	:	08/27/2015

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