MEDICARE: SUZANNE GERVAIS TREZEVANT 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		IL
2	1041C0700X	Clinical Social Worker	149010377	IL

General Provider Information

NPI Number	:	1255942660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE GERVAIS TREZEVANT LCSW

Provider Business Mailing Address
First Line	:	400 N OAK PARK AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-2123
Country	:	US
Telephone Number	:	708-415-4066
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 LAKE ST STE 417
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60301-1413
Country	:	US
Telephone Number	:	708-415-4066
Fax Number	:

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

Provider Enumeration Date	:	08/11/2020
Last Update Date	:	08/11/2020

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Directions to “ SUZANNE GERVAIS TREZEVANT LCSW” Practice Location

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