MEDICARE: ADISSON AMS MED, LPC

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		IL

General Provider Information

NPI Number	:	1811859432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADISSON AMS MED, LPC

Provider Business Mailing Address
First Line	:	2851 N RACINE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4230
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 N WELLS ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-7635
Country	:	US
Telephone Number	:	773-572-9578
Fax Number	:

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

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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