MEDICARE: RACHEL MARIE COUNTRYMAN LPC

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	178.020356	IL

General Provider Information

NPI Number	:	1508665720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHEL MARIE COUNTRYMAN LPC

Provider Business Mailing Address
First Line	:	532 W GRANT PL APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-7470
Country	:	US
Telephone Number	:	310-703-2566
Fax Number	:

Provider Business Practice Location Address
First Line	:	2353 W WABANSIA AVE APT 201
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-6641
Country	:	US
Telephone Number	:	872-216-3003
Fax Number	:

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

Provider Enumeration Date	:	03/10/2025
Last Update Date	:	03/10/2025

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