MEDICARE: MS. VIRGINIA PESA 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	180.007019	IL

General Provider Information

NPI Number	:	1801212907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIRGINIA PESA LCPC

Provider Business Mailing Address
First Line	:	967 WALNUT RIDGE CT
Second Line	:
City	:	FRANKFORT
State	:	IL
Zip	:	60423-2103
Country	:	US
Telephone Number	:	815-469-0123
Fax Number	:

Provider Business Practice Location Address
First Line	:	967 WALNUT RIDGE CT
Second Line	:
City	:	FRANKFORT
State	:	IL
Zip	:	60423-2103
Country	:	US
Telephone Number	:	815-469-0123
Fax Number	:

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

Provider Enumeration Date	:	03/13/2014
Last Update Date	:	03/13/2014

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