MEDICARE: CAMILLE MAYHALL GEHRENBECK CRC, 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	180.008156	IL

General Provider Information

NPI Number	:	1548598196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLE MAYHALL GEHRENBECK CRC, LCPC

Provider Business Mailing Address
First Line	:	4852 N HOYNE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1408
Country	:	US
Telephone Number	:	773-450-3162
Fax Number	:	773-681-7374

Provider Business Practice Location Address
First Line	:	4852 N HOYNE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1408
Country	:	US
Telephone Number	:	773-450-3162
Fax Number	:	773-681-7374

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

Provider Enumeration Date	:	11/19/2009
Last Update Date	:	04/19/2012

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