MEDICARE: EMILY CLAIRE BONANNO LPC

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	178.015255	IL

General Provider Information

NPI Number	:	1720620545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY CLAIRE BONANNO LPC

Provider Business Mailing Address
First Line	:	1935 N. SAWYER APT 3N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647
Country	:	US
Telephone Number	:	773-865-4665
Fax Number	:

Provider Business Practice Location Address
First Line	:	2071 N SOUTHPORT AVE STE 100
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4015
Country	:	US
Telephone Number	:	312-761-4707
Fax Number	:

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

Provider Enumeration Date	:	10/14/2019
Last Update Date	:	11/22/2024

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