MEDICARE: MR. NORRIS WENDELL TEAGUE LSW

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	101Y00000X	Counselor	150.107571	IL
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	150.107571	IL
3	101YM0800X	Mental Health Counselor	150.107571	IL
4	104100000X	Social Worker	150.107571	IL

General Provider Information

NPI Number	:	1922438662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NORRIS WENDELL TEAGUE LSW

Provider Business Mailing Address
First Line	:	10540 S WESTERN AVE STE 402
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2529
Country	:	US
Telephone Number	:	773-509-5055
Fax Number	:	773-509-5010

Provider Business Practice Location Address
First Line	:	10540 S WESTERN AVE STE 402
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2529
Country	:	US
Telephone Number	:	773-509-5055
Fax Number	:	773-509-5010

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

Provider Enumeration Date	:	11/15/2013
Last Update Date	:	09/27/2022

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