MEDICARE: SUSAN PROEBSTING MA 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1740990456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN PROEBSTING MA LPC

Provider Business Mailing Address
First Line	:	586 LARIUM LN
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60012-3376
Country	:	US
Telephone Number	:	847-207-6599
Fax Number	:	224-256-2649

Provider Business Practice Location Address
First Line	:	9 CRYSTAL LAKE RD STE 150
Second Line	:
City	:	LAKE IN THE HILLS
State	:	IL
Zip	:	60156-1254
Country	:	US
Telephone Number	:	815-496-0484
Fax Number	:	224-256-2649

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

Provider Enumeration Date	:	12/05/2022
Last Update Date	:	12/05/2022

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