MEDICARE: LARKSPUR COUNSELING COLLABORATIVE, PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1992559389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARKSPUR COUNSELING COLLABORATIVE, PLLC

Provider Business Mailing Address
First Line	:	1950 W SUMMERDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1039
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1950 W SUMMERDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1039
Country	:	US
Telephone Number	:	773-510-4018
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JANCEY WICKSTROM
Credential	:	LCSW
Telephone Number	:	773-510-4018

Provider Enumeration Date	:	04/12/2024
Last Update Date	:	04/12/2024

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