MEDICARE: BETH OSTLIE ED. S., NCSP

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	103TS0200X	School Psychologist	2382047	IL

General Provider Information

NPI Number	:	1578114872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH OSTLIE ED. S., NCSP

Provider Business Mailing Address
First Line	:	1457 W LELAND AVE APT 2E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-7002
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	403 ORCHARD ST
Second Line	:
City	:	FOX RIVER GROVE
State	:	IL
Zip	:	60021-1145
Country	:	US
Telephone Number	:	320-226-2269
Fax Number	:

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

Provider Enumeration Date	:	09/27/2019
Last Update Date	:	09/27/2019

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