MEDICARE: MRS. LINDA JO WEISE 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		IL

General Provider Information

NPI Number	:	1639295603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LINDA JO WEISE LCPC

Provider Business Mailing Address
First Line	:	2859 FIELDBROOK AVE
Second Line	:
City	:	WAUCONDA
State	:	IL
Zip	:	60084-5002
Country	:	US
Telephone Number	:	847-487-0370
Fax Number	:

Provider Business Practice Location Address
First Line	:	675 N NORTH CT STE 380
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60067-8131
Country	:	US
Telephone Number	:	847-327-1409
Fax Number	:	847-705-0147

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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