MEDICARE: AGNES BACON LMSW

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	6801100310	MI

General Provider Information

NPI Number	:	1457020810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGNES BACON LMSW

Provider Business Mailing Address
First Line	:	PO BOX 776982
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-6982
Country	:	US
Telephone Number	:	231-672-2119
Fax Number	:

Provider Business Practice Location Address
First Line	:	1440 E SHERMAN BLVD STE 300
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49444-1816
Country	:	US
Telephone Number	:	231-672-2008
Fax Number	:	231-672-2009

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

Provider Enumeration Date	:	09/09/2021
Last Update Date	:	03/01/2023

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