MEDICARE: MS. LOLITA GODBOLD MSW,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	149008404	IL

General Provider Information

NPI Number	:	1558722124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LOLITA GODBOLD MSW,LCSW

Provider Business Mailing Address
First Line	:	2865 W 84TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-3813
Country	:	US
Telephone Number	:	773-778-5585
Fax Number	:

Provider Business Practice Location Address
First Line	:	2865 W 84TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-3813
Country	:	US
Telephone Number	:	773-778-5585
Fax Number	:

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

Provider Enumeration Date	:	03/10/2016
Last Update Date	:	03/10/2016

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