MEDICARE: DR. LAMONT THEOLONUS TAYLOR DSW, LCSW, ACSW

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	104100000X	Social Worker	149011481	IL
2	1041C0700X	Clinical Social Worker	149011481	IL

General Provider Information

NPI Number	:	1124041199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAMONT THEOLONUS TAYLOR DSW, LCSW, ACSW

Provider Business Mailing Address
First Line	:	PO BOX 490645
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-0039
Country	:	US
Telephone Number	:	773-509-5055
Fax Number	:	773-509-5010

Provider Business Practice Location Address
First Line	:	10540 S WESTERN AVE
Second Line	:	STE 402
City	:	CHICAGO
State	:	IL
Zip	:	60643-2529
Country	:	US
Telephone Number	:	773-509-5055
Fax Number	:	773-509-5010

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2019

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