MEDICARE: MR. DAVID J EVANGELISTA 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	149-008014	IL

General Provider Information

NPI Number	:	1538273883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID J EVANGELISTA LCSW

Provider Business Mailing Address
First Line	:	2506 CHURCH ST
Second Line	:
City	:	JOHNSBURG
State	:	IL
Zip	:	60050-1916
Country	:	US
Telephone Number	:	815-578-0074
Fax Number	:	815-578-0074

Provider Business Practice Location Address
First Line	:	1400 N SEMINARY AVE
Second Line	:	SUITE #L
City	:	WOODSTOCK
State	:	IL
Zip	:	60098-2980
Country	:	US
Telephone Number	:	815-529-4489
Fax Number	:	815-308-5165

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	06/18/2010

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