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NPI Code Detail

MEDICARE: ELENA VASSALLO M.DIV., LCPC

MEDICARE: ELENA VASSALLO M.DIV., 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
1101YM0800XMental Health CounselorIL

General Provider Information

NPI Number : 1528269487
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELENA VASSALLO M.DIV., LCPC
Provider Business Mailing Address
First Line : 30 N MICHIGAN AVE STE 1920
Second Line :
City : CHICAGO
State : IL
Zip : 60602-3618
Country : US
Telephone Number : 312-263-4368
Fax Number :
Provider Business Practice Location Address
First Line : 30 N MICHIGAN AVE STE 1920
Second Line :
City : CHICAGO
State : IL
Zip : 60602-3618
Country : US
Telephone Number : 312-263-4368
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/29/2007
Last Update Date : 07/08/2007

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