MEDICARE: LIFELINE COUNSELING CENTER INC

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	251S00000X	Community/Behavioral Health Agency
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1679382204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFELINE COUNSELING CENTER INC

Provider Business Mailing Address
First Line	:	424 N THORNWOOD DR
Second Line	:
City	:	MCHENRY
State	:	IL
Zip	:	60050-5031
Country	:	US
Telephone Number	:	847-626-5001
Fax Number	:

Provider Business Practice Location Address
First Line	:	1655 N ARLINGTON HEIGHTS RD STE 301W
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-3900
Country	:	US
Telephone Number	:	847-626-5001
Fax Number	:

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	BRENDAN WAGNER
Credential	:
Telephone Number	:	773-554-5041

Provider Enumeration Date	:	01/07/2025
Last Update Date	:	01/07/2025

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