MEDICARE: FOX RIVER COUNSELING LLC

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	1041C0700X	Clinical Social Worker	149.010534	IL

General Provider Information

NPI Number	:	1821350612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOX RIVER COUNSELING LLC

Provider Business Mailing Address
First Line	:	150 HOUSTON ST
Second Line	:	SUITE 300
City	:	BATAVIA
State	:	IL
Zip	:	60510-1953
Country	:	US
Telephone Number	:	847-909-3764
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 HOUSTON ST
Second Line	:	SUITE 300
City	:	BATAVIA
State	:	IL
Zip	:	60510-1953
Country	:	US
Telephone Number	:	847-909-3764
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MRS. MARIANNE K KELLY
Credential	:	LCSW
Telephone Number	:	847-909-3764

Provider Enumeration Date	:	06/08/2012
Last Update Date	:	06/22/2012

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