MEDICARE: MS. BETH ANN DALY CADC, MISA II, NCRS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	12211	IL

General Provider Information

NPI Number	:	1386861680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BETH ANN DALY CADC, MISA II, NCRS

Provider Business Mailing Address
First Line	:	4735 N BEACON ST APT 402
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-4866
Country	:	US
Telephone Number	:	773-506-9520
Fax Number	:	773-506-9531

Provider Business Practice Location Address
First Line	:	4735 N BEACON ST APT 402
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-4866
Country	:	US
Telephone Number	:	773-506-9520
Fax Number	:	773-506-9531

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

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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