MEDICARE: TAMMY LICATA

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1023274081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY LICATA

Provider Business Mailing Address
First Line	:	234 WOOD GLEN LN
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1535
Country	:	US
Telephone Number	:	630-993-0953
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 E CHICAGO AVE
Second Line	:	SUITE 151
City	:	NAPERVILLE
State	:	IL
Zip	:	60540-5526
Country	:	US
Telephone Number	:	630-305-4196
Fax Number	:

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

Provider Enumeration Date	:	07/30/2008
Last Update Date	:	07/30/2008

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