MEDICARE: MS. STEPHANIE NICOLE TERRELL LCPC, BC-DMT

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	101Y00000X	Counselor	180.012542	IL

General Provider Information

NPI Number	:	1811537806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STEPHANIE NICOLE TERRELL LCPC, BC-DMT

Provider Business Mailing Address
First Line	:	1300 W BELMONT AVE STE 301
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3241
Country	:	US
Telephone Number	:	773-880-1310
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 W BELMONT AVE STE 301
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-3241
Country	:	US
Telephone Number	:	773-880-1310
Fax Number	:

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

Provider Enumeration Date	:	01/08/2020
Last Update Date	:	11/27/2023

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