MEDICARE: RYAN ROLLINSON 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	149.019172	IL

General Provider Information

NPI Number	:	1306210190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN ROLLINSON LCSW

Provider Business Mailing Address
First Line	:	1046 W CATALPA AVE APT 2E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1539
Country	:	US
Telephone Number	:	612-532-9027
Fax Number	:

Provider Business Practice Location Address
First Line	:	5340 N CLARK ST STE 212
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-2120
Country	:	US
Telephone Number	:	612-532-9027
Fax Number	:

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

Provider Enumeration Date	:	11/17/2015
Last Update Date	:	03/17/2018

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