MEDICARE: AVITAL FRIEDLAND 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	149.022224	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F634-0029-1972	OTHER	IL	DRIVER'S LICENSE

General Provider Information

NPI Number	:	1548770936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AVITAL FRIEDLAND LCSW

Provider Business Mailing Address
First Line	:	3511 N WILTON AVE APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1941
Country	:	US
Telephone Number	:	574-329-4162
Fax Number	:

Provider Business Practice Location Address
First Line	:	3511 N WILTON AVE APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1941
Country	:	US
Telephone Number	:	574-329-4162
Fax Number	:

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

Provider Enumeration Date	:	10/11/2017
Last Update Date	:	10/25/2023

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