MEDICARE: LARIZA FENNER-LUX

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	180009362	IL

General Provider Information

NPI Number	:	1902335714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARIZA FENNER-LUX

Provider Business Mailing Address
First Line	:	4951 W MEDILL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-3209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4951 W MEDILL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-3209
Country	:	US
Telephone Number	:	773-418-0164
Fax Number	:

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

Provider Enumeration Date	:	06/06/2017
Last Update Date	:	06/06/2017

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