MEDICARE: MRS. ALISSA ANN EDGE MA, 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	101YM0800X	Mental Health Counselor	180014512	IL

General Provider Information

NPI Number	:	1720611197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALISSA ANN EDGE MA, LCPC

Provider Business Mailing Address
First Line	:	640 N LA SALLE DR STE 275
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-3754
Country	:	US
Telephone Number	:	937-477-7545
Fax Number	:

Provider Business Practice Location Address
First Line	:	1227 W SCHOOL ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1425
Country	:	US
Telephone Number	:	937-477-7545
Fax Number	:

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

Provider Enumeration Date	:	02/13/2020
Last Update Date	:	12/11/2024

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