MEDICARE: MR. JAMES THEODORE GREEN SR. LCPC

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01636560	OTHER	IL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1902921299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES THEODORE GREEN SR. LCPC

Provider Business Mailing Address
First Line	:	7400 S RACINE AVE
Second Line	:	SUITE 101
City	:	CHICAGO
State	:	IL
Zip	:	60636-4114
Country	:	US
Telephone Number	:	773-874-9715
Fax Number	:	773-874-9715

Provider Business Practice Location Address
First Line	:	7400 S RACINE AVE
Second Line	:	SUITE 101
City	:	CHICAGO
State	:	IL
Zip	:	60636-4114
Country	:	US
Telephone Number	:	773-874-9715
Fax Number	:	773-874-9715

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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