MEDICARE: MRS. MIA FIORE ROSENTHAL JENSEN 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	180.013961	IL

General Provider Information

NPI Number	:	1760192975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MIA FIORE ROSENTHAL JENSEN LCPC

Provider Business Mailing Address
First Line	:	214 E SCRANTON AVE
Second Line	:
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-2532
Country	:	US
Telephone Number	:	847-477-7346
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 S MARION ST
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-2826
Country	:	US
Telephone Number	:	847-477-7346
Fax Number	:

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

Provider Enumeration Date	:	11/29/2022
Last Update Date	:	11/29/2022

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