MEDICARE: LYNETTE CAROL IMDIEKE-STRUZYK MS, LPCC

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	CC00183	MN
2	101YM0800X	Mental Health Counselor	CC00183	MN
3	101YP2500X	Professional Counselor	CC00183	MN
4	103TC1900X	Counseling Psychologist	CC00183	MN

General Provider Information

NPI Number	:	1942502133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNETTE CAROL IMDIEKE-STRUZYK MS, LPCC

Provider Business Mailing Address
First Line	:	6069 HIDDEN LN
Second Line	:
City	:	SOUTH HAVEN
State	:	MN
Zip	:	55382-4505
Country	:	US
Telephone Number	:	320-255-9188
Fax Number	:

Provider Business Practice Location Address
First Line	:	6069 HIDDEN LN
Second Line	:
City	:	SOUTH HAVEN
State	:	MN
Zip	:	55382-4505
Country	:	US
Telephone Number	:	320-255-9188
Fax Number	:

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

Provider Enumeration Date	:	11/22/2010
Last Update Date	:	11/22/2010

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