MEDICARE: AMANDA EKMAN 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	149.021004	IL

General Provider Information

NPI Number	:	1508309584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA EKMAN LCSW

Provider Business Mailing Address
First Line	:	6601 N AVONDALE AVE STE 101
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-1567
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6601 N AVONDALE AVE STE 101
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-1567
Country	:	US
Telephone Number	:	773-774-4444
Fax Number	:	773-774-4447

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

Provider Enumeration Date	:	11/23/2016
Last Update Date	:	03/13/2020

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