MEDICARE: MISS KATHLEEN MARIE PENDERGAST 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	180.007897	IL
2	101YP2500X	Professional Counselor	180007897	IL

General Provider Information

NPI Number	:	1750634358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KATHLEEN MARIE PENDERGAST LCPC

Provider Business Mailing Address
First Line	:	1320 W ROSCOE ST # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1414
Country	:	US
Telephone Number	:	574-261-7547
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647
Country	:	US
Telephone Number	:	773-217-8834
Fax Number	:

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

Provider Enumeration Date	:	10/19/2012
Last Update Date	:	01/30/2020

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