MEDICARE: DENNIS POMERLEAU LCSW

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	149.009177	IL

General Provider Information

NPI Number	:	1184720195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS POMERLEAU LCSW

Provider Business Mailing Address
First Line	:	4256 N RAVENSWOOD AVE
Second Line	:	SUITE 311
City	:	CHICAGO
State	:	IL
Zip	:	60613-1110
Country	:	US
Telephone Number	:	773-490-8972
Fax Number	:

Provider Business Practice Location Address
First Line	:	4256 N RAVENSWOOD AVE
Second Line	:	SUITE 311
City	:	CHICAGO
State	:	IL
Zip	:	60613-1110
Country	:	US
Telephone Number	:	773-490-8972
Fax Number	:

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	04/27/2011

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