MEDICARE: AUDRA ELIZABETH KURTH 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	1041C0700X	Clinical Social Worker	180.008636	IL
2	101YM0800X	Mental Health Counselor	180008636	IL

General Provider Information

NPI Number	:	1457797987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDRA ELIZABETH KURTH LCPC

Provider Business Mailing Address
First Line	:	2737 W AINSLIE ST UNIT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2715
Country	:	US
Telephone Number	:	309-287-7216
Fax Number	:

Provider Business Practice Location Address
First Line	:	4054 N LINCOLN AVE # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3038
Country	:	US
Telephone Number	:	309-287-7216
Fax Number	:

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

Provider Enumeration Date	:	05/10/2013
Last Update Date	:	08/14/2019

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