MEDICARE: MEGAN GREENE COUNSELING, LLC

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1316473069	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1619539442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEGAN GREENE COUNSELING, LLC

Provider Business Mailing Address
First Line	:	3215 N ELSTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-5850
Country	:	US
Telephone Number	:	989-600-6239
Fax Number	:

Provider Business Practice Location Address
First Line	:	2539 N KEDZIE BLVD STE 5E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1435
Country	:	US
Telephone Number	:	872-903-3829
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MEGAN GREENE
Credential	:	LCPC
Telephone Number	:	989-600-6239

Provider Enumeration Date	:	07/02/2019
Last Update Date	:	07/10/2019

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