MEDICARE: STEPHANIE L ROTH 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	180.006723	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	180.006723	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1720254857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE L ROTH LCPC

Provider Business Mailing Address
First Line	:	5710 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-4302
Country	:	US
Telephone Number	:	773-728-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5710 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-4302
Country	:	US
Telephone Number	:	773-728-1000
Fax Number	:

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

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	05/08/2008

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Directions to “ STEPHANIE L ROTH LCPC” Practice Location

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