MEDICARE: DORI PEACE, 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	180006048	IL

General Provider Information

NPI Number	:	1972858058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DORI PEACE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 617614
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-7614
Country	:	US
Telephone Number	:	312-577-7630
Fax Number	:	312-233-0063

Provider Business Practice Location Address
First Line	:	200 E RANDOLPH ST
Second Line	:	SUITE 5100
City	:	CHICAGO
State	:	IL
Zip	:	60601-6436
Country	:	US
Telephone Number	:	312-577-7630
Fax Number	:	312-233-0063

Authorized Official
Title or Position	:	OWNER
Name	:	DORIS PEACE KRASNOPOLSKY
Credential	:	LCPC
Telephone Number	:	312-577-7630

Provider Enumeration Date	:	07/16/2012
Last Update Date	:	07/16/2012

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