MEDICARE: RONALD W KANWISCHER CADC

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	180-000692	IL
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	180-000692	IL

General Provider Information

NPI Number	:	1619955267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD W KANWISCHER CADC

Provider Business Mailing Address
First Line	:	PO BOX 19642
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62794-9642
Country	:	US
Telephone Number	:	217-545-8000
Fax Number	:	217-545-2275

Provider Business Practice Location Address
First Line	:	319 E MADISON ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62701-1035
Country	:	US
Telephone Number	:	217-545-8000
Fax Number	:	217-545-2275

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

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	10/03/2018

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