MEDICARE: RAVENSWOOD COUNSELING CENTER CO

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

General Provider Information

NPI Number	:	1992378616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAVENSWOOD COUNSELING CENTER CO

Provider Business Mailing Address
First Line	:	4453 N ROCKWELL ST APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3057
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4611 N RAVENSWOOD AVE STE 105
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-7569
Country	:	US
Telephone Number	:	773-321-6410
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MEGAN K BRENNAN
Credential	:
Telephone Number	:	773-895-2125

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	07/20/2021

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