MEDICARE: GEORGE BRASSEA III 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	180.011327	IL
2	101YP2500X	Professional Counselor		IL

General Provider Information

NPI Number	:	1528420213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE BRASSEA III LCPC

Provider Business Mailing Address
First Line	:	210 N ARQUILLA DR
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-1702
Country	:	US
Telephone Number	:	708-769-5015
Fax Number	:

Provider Business Practice Location Address
First Line	:	222 VOLLMER RD STE AA
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-1886
Country	:	US
Telephone Number	:	708-248-7039
Fax Number	:

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

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	03/06/2024

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