MEDICARE: MARK PETROELJE, 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	101YP2500X	Professional Counselor	180008805	IL

General Provider Information

NPI Number	:	1821441494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK PETROELJE, LLC

Provider Business Mailing Address
First Line	:	1000 W DIVERSEY PKWY
Second Line	:	SUITE 260
City	:	CHICAGO
State	:	IL
Zip	:	60614-1879
Country	:	US
Telephone Number	:	312-502-9014
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 W DIVERSEY PKWY
Second Line	:	SUITE 260
City	:	CHICAGO
State	:	IL
Zip	:	60614-1879
Country	:	US
Telephone Number	:	312-502-9014
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PROFESSIONAL COUNSELOR
Name	:	MARK ROBERT PETROELJE
Credential	:	LCPC
Telephone Number	:	312-502-9014

Provider Enumeration Date	:	07/19/2016
Last Update Date	:	07/19/2016

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