MEDICARE: SERENA PESCH

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	1041C0700X	Clinical Social Worker	149.017368	IL

General Provider Information

NPI Number	:	1144606385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERENA PESCH

Provider Business Mailing Address
First Line	:	5215 N RAVENSWOOD AVE
Second Line	:	STE 210
City	:	CHICAGO
State	:	IL
Zip	:	60640-1670
Country	:	US
Telephone Number	:	773-654-3179
Fax Number	:	773-973-0353

Provider Business Practice Location Address
First Line	:	5215 N RAVENSWOOD AVE
Second Line	:	STE 210
City	:	CHICAGO
State	:	IL
Zip	:	60640-1670
Country	:	US
Telephone Number	:	773-654-3179
Fax Number	:	773-973-0353

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

Provider Enumeration Date	:	08/10/2015
Last Update Date	:	05/19/2019

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