MEDICARE: MR. BERT FOX 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	180.012648	IL

General Provider Information

NPI Number	:	1770097396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BERT FOX LCPC

Provider Business Mailing Address
First Line	:	5412 N CLARK ST STE 227
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1223
Country	:	US
Telephone Number	:	773-673-9095
Fax Number	:

Provider Business Practice Location Address
First Line	:	5412 N CLARK ST STE 227
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1223
Country	:	US
Telephone Number	:	773-673-9095
Fax Number	:

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

Provider Enumeration Date	:	11/17/2017
Last Update Date	:	12/20/2019

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Directions to “ MR. BERT FOX LCPC” Practice Location

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