MEDICARE: MARINA GARAVAGLIA M.S.W., L.S.

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	101YM0800X	Mental Health Counselor	390200000X	IL

General Provider Information

NPI Number	:	1457633703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA GARAVAGLIA M.S.W., L.S.

Provider Business Mailing Address
First Line	:	1205 W SHERWIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-2263
Country	:	US
Telephone Number	:	847-338-7533
Fax Number	:

Provider Business Practice Location Address
First Line	:	1205 W SHERWIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-2263
Country	:	US
Telephone Number	:	847-338-7533
Fax Number	:

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

Provider Enumeration Date	:	09/13/2011
Last Update Date	:	10/10/2011

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